Fatal invasive aspergillosis in an adolescent with cystic fibrosis

We report on a 13-year-old girl with cystic fibrosis (CF) who developed refractory airflow obstruction despite high-dose steroids. She developed invasive aspergillosis and died despite oral and intravenous antifungal therapy. We speculate that the increasing use of immunosuppressive strategies and aggressive antipseudomonal therapy in CF may lead to an increase in aspergillus lung disease, including invasive aspergillosis in the future.     

A case of idiopathic pulmonary upper lobe fibrosis complicated by invasive pulmonary aspergillosis]

A 72-year-old man with idiopathic pulmonary upper lobe fibrosis who had been followed for a year developed a high fever and yellow sputum in July 2001. Chest radiography and chest computed tomography (CT) showed a rapidly enlarging cavity with an internal mass and infiltration in the left upper lung field. Pulmonary aspergillosis was diagnosed by examination of bronchoalveolar lavage fluid (BALF). Administration of itraconazole improved his condition. The concentrations of surfactant proteins A (SP-A) and D (SP-D) in serum and in BALF were decreased during the clinical course. It is known that SP-A and SP-D are critical factors for host defense against aspergillus. The lowering of SP-A and SP-D in the serum and BALF seemed to reflect destructive changes of lung structure and impaired innate lung immunity that could to lead invasive pulmonary aspergillosis.     

Two cases of successfully treated invasive pulmonary aspergillosis following influenza virus infection]

While invasive pulmonary aspergillosis usually occurs in immunocompromised hosts, it has been described after influenza virus infection in healthy individuals. The first case was a 76-year-old previously healthy woman admitted because of chest pain, cough, sputum, fever, and a chest radiograph abnormality. A transbronchial biopsy specimen showed fungal hyphae. Amphotericin B (AMPH) and Itraconazole (ITCZ) were given, and she improved gradually. A viral test showed a titre of 1/128 to influenza A. Case 2 was a 72-year-old previously healthy man admitted because of cough, fever, chest pain and a consolidation and cavitation on the chest radiograph. Antibiotics were ineffective. Cavitation with a halo sign appeared on the contralateral lung. Because his daughter was infected with Influenza B, we suspected he had been infected with IPA following influenza infection. AMPH and ITCZ and Micafungin sodium were given. His respiratory failure worsened, and on the tenth hospital day he required artificial ventilation; his condition improved gradually, (extubation after 40 days.) A viral test showed a titre of 1/128 to influenza B. IPA must be considered for the differential diagnosis of complications of influenza virus infection.     

Invasive pulmonary aspergillosis following influenza A infection]

A 55-year-old man with arc welder's pneumoconiosis who presented with bilateral pneumonia was admitted to our hospital. Streptococcus pneumoniae and Aspergillus fumigatus were cultured from sputum on admission. The patient was treated with antibiotics and an anti-fungal agent, but his chest radiograph shadows became exacerbated, and he died of respiratory failure on the fourth day of hospitalization. Histological examination of postmortem lung tissue revealed necrotizing aspergillous pneumonia. The results of hemagglutination inhibition tests for influenza A (H3 N2) were x16 in September 1999, and x512 on the third day of hospitalization. We diagnosed this patient's condition as invasive pulmonary aspergillosis associated with influenza A viral infection. The suppression of cellular immunity, lymphocytopenia, and destruction of airways-mucociliary transport induced by influenza A viral infection were suspected to have predisposed him to aspergillus superinfection.     

Invasive pulmonary aspergillosis associated with influenza B

Invasive pulmonary aspergillosis (IPA) usually occurs in immunocompromised patients. However, rarely, this infection can occur in normal hosts. This review of the literature identified 13 cases of IPA associated with influenza, of which 12 had influenza A and the type of influenza was not mentioned in the other case. Reported here is a case of IPA, which was associated with influenza B, in a 63-year-old immunocompetent woman. Her lungs showed gross invasion and she was treated with itraconazole and amphotericin B. She required mechanical ventilation for about 5 months but recovered completely. This is the first reported case of IPA associated with influenza B.     

A case of sarcoidosis and idiopathic thrombocytopenic purpura accompanied with invasive pulmonary aspergillosis]

A 54-year-old woman with a 21-year history of sarcoidosis was admitted to our hospital with dyspnea on exertion, weight loss, and the appearance of consolidation in chest radiographs. The serum level of soluble IL-2 receptor was high, and CT findings demonstrated mediastinal, hilar and abdominal lymphadenopathy. The histological findings of subpleural consolidation in a transbronchial lung biopsy of the left lung showed giant cells; and those of a CT-assisted biopsy of a retroperitoneal lymph node revealed non-caseous epithelioid cell granulomas. After the biopsy, severe thrombocytopenia (6,000/microliter) developed. With prednisolone treatment, the platelet count rose to normal and the subpleural consolidation on chest radiography was improved. Five weeks later, the had a productive cough with fever, rapidly progressive cavitary lesions and consolidation on chest radiography. Aspergillus fumigatus was detected in the sputum by PCR, and Aspergillus antigen was detected in the serum. She died of progressive respiratory failure, in spite of therapy with amphotericin B and itraconazole. We report a rare case of sarcoidosis and idiopathic thrombocytopenic purpura accompanied with invasive pulmonary aspergillosis.     

Fatal invasive pulmonary aspergillosis presenting as profound hypoglycemia in a patient with anorexia nervosa

A 29-year-old woman with anorexia nervosa was admitted because of an episode of severe and persistent hypoglycemia. Chest X-ray showed multiple cavitary lesions and subsequent sputum culture revealed heavy growth of Aspergillus niger. In spite of intensive antimicrobial and supportive therapy, the patient died of respiratory failure and cardiovascular collapse. The potential relationships between anorexia nervosa, hypoglycemia, and infection are discussed.     

降钙素原在鉴别特发性肺纤维化急性加重和合并肺部细菌感染中的临床价值

目的：评价降钙素原(PCT)在特发性肺纤维化急性加重及特发性肺纤维化合并肺部细菌感染中的鉴别诊断作用。方法共入选15例特发性肺纤维化急性加重和15例特发性肺纤维化无急性加重伴肺部细菌感染患者。入选第1天、第7天测定各项炎症指标,采用免疫比浊法检测 C 反应蛋白(CRP),同时采用双抗体夹心免疫荧光法测定血 PCT 浓度并进行比较,记录患者白细胞和中性粒细胞计数。结果特发性肺纤维化伴肺部感染组 PCT 浓度明显高于特发性肺纤维化急性加重组[(1.89±0.31)μg/L vs (0.72±0.40)μg/L,P =0.001]。特发性肺纤维化伴肺部感染组 CRP 浓度为(75.13±33.40)mg/L,特发性肺纤维化急性加重组浓度为(53.61±23.52)mg/L,两组比较差异无统计学意义(P >0.05)。结论①PCT 鉴别特发性肺纤维化急性加重和特发性肺纤维化合并肺部感染的敏感性较传统炎症指标高。②PCT 在特发性肺纤维化急性加重患者中并无明显升高。③PCT 诊断特发性肺纤维化合并肺部感染的敏感性、特异性、诊断正确率均较 CRP 等传统炎症指标高。     

Infection of TT virus in patients with idiopathic pulmonary fibrosis

The precipitating factors of idiopathic pulmonary fibrosis (IPF) have not been elucidated. Recently, a novel DNA virus named TTvirus (TTV) was discovered in a patient with post-transfusion hepatitis of unknown aetiology TTV is a circular, single-stranded DNA virus of 3.8 kB. To evaluate the relationship between TTV and IPF, the sera of 33 patients with IPF were tested for the presence of TTV DNA by semi-nested polymerase chain reaction. TTV DNA was detected in 12 (36.4%) IPF patients. The serum lactate dehydrogenase (LDH) level was significantly higher in the IPF patients withTTV than in those without TTV (802 +/- 121 vs. 530 +/- 49 IU l(-1), p < 0.05). Six (50%) of 12 patients in theTTV DNA-positive group died during the observation period, while only six (28.6%) of 21 patients in theTTV DNA-negative group died. The 3-year-survival rate was significantly lower in the TTV DNA-positive group than in theTTV DNA-negative group (58-3% vs. 95.2%, P <0-02). Replicative intermediate forms of TTV DNA were detected in the lung specimen from a TTV-infected IPF patient. TTV infection influences the disease activityand prognosis of IPF in some cases. Further studies are required to elucidate the clinical significance of TTV in IPF.     

Cytomegalovirus infection with idiopathic pulmonary fibrosis. Diagnosis suggested by bronchoalveolar lavage

Bronchoalveolar lavage was used to provide important diagnostic information for a patient found to have idiopathic pulmonary fibrosis and concomitant cytomegalovirus infection. The use of this procedure may not only provide useful information regarding the underlying disease, but may also suggest alternative diagnostic possibilities.     

A case of invasive broncho-pulmonary aspergillosis associated with influenza A (H3N2) infection]

A 49-year-old man with high alcohol consumption was admitted with fever, cough and progressive dyspnea after a one week history of influenza-like symptoms. Chest X-ray film on admission showed diffuse peribronchial shadows and patchy infiltration in the right lower lung field. Chest X-ray film the following day and chest CT film on the 4th day of admission showed multiple nodular shadows and cavity formation. At bronchoscopy the bronchial surface was covered by white plaque, and Asp. fumigatus was subsequently cultured from BAL fluid. On the basis of suspected invasive pulmonary aspergillosis, anti-fungal agents were commenced. However, the shadows on chest X-ray increased, and the patient died on the 10th day of admission of respiratory failure and septic shock. Histological examination revealed bronchial wall invasion by hyphae of aspergillus and abscess formation in the pulmonary parenchyma. The precipitin antibody against aspergillus antigen was positive in reserved serum. Anti-Influenza A virus antibody (CF) was positive (X 256), and hemagglutination inhibition test of Influenza A (H3N2) was positive (X 2048) in serum on admission. The suppression of cellular immunity and destruction of the mucociliary system of airways induced by Influenza A infection was suspected to have predisposed to aspergillus superinfection.     

Chronic necrotizing pulmonary aspergillosis following an infection by Mycobacterium malmoense

Pneumonia due to Mycobacterium malmoense is rare and usually occurs in damaged lung as is the case with Aspergillus infections. We report the case of a patient who developed chronic necrotizing pulmonary aspergillosis following an infection by atypical mycobacteria. A 53-year-old woman was hospitalized because of weight loss and fever. Direct examination of sputum smear was positive for acid fast bacilli and PCR and culture led to the diagnosis of infection with M. malmoense. Treatment was begun with clarithromycin, rifampicin and ethambutol. Despite initial improvement and excellent adherence to treatment, fever and weight loss recurred 6 months later. Relapse of the mycobacterial infection was excluded and the final diagnosis was necrotizing pulmonary aspergillosis. Infection with A. fumigatus complicating the treatment of M. malmoense is unusual. The management is challenging because of strong interactions between voriconazole and rifampicin, and thus requires a multidisciplinary and specialized approach.     

Successful treatment of invasive pulmonary aspergillosis in an immunocompetent host

Immunocompromised individuals are susceptible to pulmonary Aspergillus infection, but invasive Aspergillus infection is extremely rare in the presence of normal immunity. A case of invasive pulmonary aspergillosis in an immunocompetent 57-year-old female who was successfully treated with liposomal amphotericin-B is reported here.     

Segmental wall motion abnormalities in an individual with idiopathic pulmonary hemosiderosis

Idiopathic pulmonary hemosiderosis (IPH) is a rare condition characterized by diffuse pulmonary hemorrhage of unknown etiology. Cardiac involvement in the form of myocarditis and right ventricular hypertrophy have been reported to occur in association with IPH, although findings on echocardiography have not been described. Herein is presented a case of an adult with IPH and echocardiographic abnormalities.     

Clinical characterization of interleukin-8 in patients with idiopathic pulmonary fibrosis]

The levels of interleukin-8 (IL-8) in the serum, bronchoalveolar fluid (BALF) and epithelial lining fluid (ELF) were measured in patients with idiopathic pulmonary fibrosis. (IPF), in order to evaluate the clinical significance of IL-8. The serum levels were significantly higher in patients with active IPF (34.4 +/- 11.9 pg/ml, n = 8) than in those with stable IPF (mean: 14.6 +/- 10.9 pg/ml, n = 18), but neither correlated with the serum level of KL-6 or of SP-D, or with the intensity of chest Ga67-scintigraphy. There were no significant differences in BALF or ELF IL-8 levels between the active and stable IPF groups. These results suggest that the serum level of IL-8 is a useful marker for evaluating the disease activity in patients with IPF.