A Case of Aspergillus fumigatus Mediastinitis After Heart Surgery in Madani Heart Center, Tabriz, Iran

Reported here is the case of a 60-year-old male diabetic patient with mediastinitis caused by Aspergillus fumigatus following an open heart surgery that was successfully treated. A review of literature revealed that A. fumigatus as a cause of mediastinitis has been rarely described. Aspergillus infection should be considered in the differential diagnosis of mediastinitis after cardiac surgery, especially in a clinical setting of unexplained sepsis or nonhealing wound infection despite apparently adequate treatment.     

Invasive aspergillosis of the lung and pericardium in a nonimmunocompromised 33 year old man

In a 33 year old man with no discernible immunologic defect, invasive aspergillosis developed in both the pericardium and lung with marked granulomatous reaction. The patient received 2 g of intravenous amphotericin B over eight weeks, with partial regression of the pulmonary infiltrate and disappearance of symptoms. However, five months later, he returned with marked progression of his disease. Evaluation of host defense, including granulocyte and lymphocyte function, was normal. The patient was given an additional 3 g of amphotericin B over nine weeks with marked improvement in symptoms and chest roentgenogram. At six-month follow-up, he was asymptomatic with a stable radiographic appearance. A recurrence in symptoms and the pulmonary infiltrate was noted two months later. He was treated with an additional course of amphotericin and currently is receiving ketoconazole in hopes of suppressing the infection. We could find no immune impairment to explain the severe pulmonary and pericardial disease due to Aspergillus flavus in this young man.     

Significance of isolation of Aspergillus from the respiratory tract in diagnosis of invasive pulmonary aspergillosis. Results from a three-year prospective study

The isolation of Aspergillus species from respiratory secretions has been regarded as being of limited usefulness in the antemortem diagnosis of invasive pulmonary aspergillosis. One hundred and eight consecutive patients were evaluated in whom Aspergillus species were isolated from respiratory secretions. Invasive aspergillosis was not demonstrated in non-immunosuppressed patients or in patients with solid tumors in the absence of neutropenia. Lung tissue was examined in 17 patients with leukemia and/or neutropenia; all had invasive aspergillosis. Tissue examination was not performed in 20 neutropenic patients; of 17 not receiving antifungal therapy, 16 died. Multivariate statistical analysis showed that neutropenia and absence of cigarette smoking were significant predictors of invasive aspergillosis in patients with respiratory tract cultures yielding Aspergillus. All cases of invasive aspergillosis were associated with A. fumigatus or A. flavus. The isolation of A. fumigatus or A. flavus from the respiratory tract of a patient with leukemia and/or neutropenia is highly predictive of invasive infection. Empiric amphotericin B therapy, without the necessity for tissue diagnosis, should be considered in this patient subgroup.     

Successful treatment of post-mitral valve annuloplasty Aspergillus flavus endocarditis

Aspergillus endocarditis is associated with a very high mortality. Of approximately 67 cases reported in the English language literature, there have been only two known survivors. This report describes a patient with Aspergillus flavus endocarditis after mitral valve annuloplasty who recovered with combined surgical and antifungal therapy. This is the first successfully treated case due to A. flavus and the first involving an annuloplasty ring.     

Disseminated fungal infection following falciparum malaria

Falciparum malaria can cause immune suppression sufficient to allow opportunistic infection during the recovery phase. A patient is described who died from a disseminated infection with Aspergillus flavus and Absidia corymbifera, unresponsive to treatment with amphotericin and voriconazole.     

Aspergillus mediastinitis following orthotopic heart transplantation: case report and review of the literature

Bacterial mediastinitis after orthotopic heart transplantation (OHT) is well described in the literature. However, little information has been published on fungal mediastinitis in this population. We describe a man with Aspergillus fumigatus mediastinitis diagnosed 10 weeks after OHT. The patient was treated with voriconazole. The literature on Aspergillus mediastinitis is also reviewed.     

Diagnosis of pulmonary infection caused by Aspergillus: usefulness of respiratory cultures

Aspergillus infection is often difficult to diagnose, and the usefulness of methods of culture for diagnosis has been questioned. We reviewed all respiratory cultures that yielded any species of Aspergillus and all surgical and autopsy materials suspected or diagnostic of infection with Aspergillus over a two-year period. Of 89 patients with one or more positive cultures of nonbiopsy respiratory tract specimens, eight had histologically proven disease (three had aspergillomas and five, invasive aspergillosis). All cases of disease were due to Aspergillus fumigatus or Aspergillus flavus, and eight of nine patients with two or more positive cultures of A. fumigatus or A. flavus had proven disease, versus one of 81 who were uninfected (P less than .001). Cultures from infected patients also had heavier growth and contained mixed Aspergillus species less often than did cultures from uninfected patients. We conclude that cultures of respiratory specimens are useful for diagnosis of pulmonary infection caused by Aspergillus.     

Characterization of antigens from Aspergillus fumigatus. III. Comparison of antigenic relationships of clinically important aspergilli.

Antigenic relationships between strains of Aspergillus fumigatus, Aspergillus fumigatus var. elipticus, Aspergillus phialiseptus, Aspergillus flavus, and Aspergillus niger were analyzed by fused rocket immunoelectrophoresis and by skin tests. Seventy-three to 89 % of the numbers of antigens detected between strains and species of the A. fumigatus series were shared. The degree of sharing between antigens of A. flavus, A. fumigatus series, and A. niger was much lower and ranged from 19 to 35 %. In reciprocal skin tests in sensitized guinea pigs, similar relationships were shown. Three fractions of A. fumigatus extract proved to be markedly specific for this species. Cross reactivity was associated primarily with carbohydrate and glycoprotein fractions.     

Aspergillus flavus endocarditis on a native valve

A 33 year old female had febrile aplasia following a first chemotherapy treatment for acute T lymphoid leukaemia. She was transferred to intensive care for acute respiratory distress due to bilateral pneumonia with Stenotrophomonas maltophilia septicaemic shock. After an initial improvement with antibiotic treatment, she developed multiple necrotic cutaneous lesions. A skin biopsy showed the presence of Aspergillus flavus in large quantities in the vascular lumina. Echocardiography revealed a voluminous vegetation on the mitral valve supporting aspergillus endocarditis. Despite antifungal treatment, shock and coma developed rapidly. Cerebral CT scan suggested multiple septic emboli. Within several hours, the scenario progressed towards multiorgan failure leading the death of the patient. Aspergillus endocarditis is exceptional and usually only occurs in immunosuppressed patients. The diagnosis is difficult, and the prognosis is appalling with a mortality greater than 90% despite treatment.     

Aspergillus species endocarditis. The new face of a not so rare disease

Aspergillus flavus endocarditis developed in a 13 year old girl after mitral valve replacement. Thirty-nine other cases of Aspergillus species endocarditis were found in the medical literature. Twenty-nine of these infections occurred in postcardiac surgery patients. Fever was the most common presenting manifestation (35 patients). Cardiac murmurs were present in 25. Lesions were in the left side of the heart in 38 (95 per cent), and there were major arterial emboli in 33 (83 per cent).The diagnosis was made antemortem in only nine patients. The diagnostic specimen in eight of these was an embolus. Aspergillus sp. were cultured from the blood of only three (8 per cent). Two (5 per cent) patients survived; in both infected prostheses were replaced, and one received antifungal chemotherapy. Aspergillus sp. endocarditis should be suspected in any postcardiac surgery patient presenting with endocarditis and emboli whose blood yields no organisms in culture.Careful surveillance and control of fungal contamination of the surgical environment is urged. Cultures of arterial blood should be obtained, and both solid and liquid microbiological media utilized. Early valve replacement and chemotherapy with both amphotericin B and flucytosine are recommended.     

Conservative treatment of malignant (invasive) external otitis caused by Aspergillus flavus with oral itraconazole solution in a neutropenic patient

Aspergillus flavus causes invasive external otitis associated with severe infection of the skull base. A combination of amphotericin B, surgical debridement and long-term itraconazole is considered the therapy of choice. We report a case of invasive external otitis due to A. flavus that was treated successfully with a short course of amphotericin B and long-term oral itraconazole without surgical intervention.     

Aspergillus vegetative endocarditis and complete heart block in a patient with acute leukemia.

Aspergillus flavus vegetative endocarditis together with myocardial abscesses and pneumonitis developed in a patient with acute lymphocytic leukemia. The initial diagnosis was not suspected until 67gallium imaging revealed a radiographically undetectable thoracic abnormality. Despite apparently "early" diagnosis, antifungal therapy was inadequate to prevent disruption of the bundle of His, complete heart block and death.     

A case of bronchocentric granulomatosis associated with uveitis]

A 32-year-old female was admitted to our hospital because of abnormal pulmonary shadows and a decrease in visual acuity. Analysis of peripheral blood revealed eosinophilia, and chest roentgenogram demonstrated multiple infiltrates in the right upper lung field. Pathological examination of transbronchial lung biopsy specimens revealed necrotizing granulomatous lesions in the walls of bronchioles, and a definitive diagnosis of bronchocentric granulomatosis was made. The cause of bronchocentric granulomatosis in this patient was suggested to be an allergic reaction to Aspergillus because of positive response to skin test for Aspergillus. Although it is reported that extrapulmonary involvement is rare in bronchocentric granulomatosis, the present case was associated with uveitis, and to our knowledge is the first reported case.     

Endemic and epidemic aspergillosis associated with in-hospital replication of Aspergillus organisms

When a new hospital opened in 1983, environmental culturing for Aspergillus organisms and surveillance for nosocomial aspergillosis cases were begun to characterize the relationship between environmental contamination and infection. Monthly air sampling demonstrated increasing concentrations of Aspergillus flavus and Aspergillus fumigatus to mean levels greater than 1 cfu/m3 during 1986-1987, accompanied by a progressive increase in incidence of aspergillosis to 1.2% in immunocompromised patients. This prompted an inspection that revealed heavy growth of Aspergillus organisms on air filters. Subsequent inspections of hospital wards showed small foci of A. flavus growth on other materials. Removal of the contaminated filters and improved environmental maintenance were associated with reduction in A. flavus and A. fumigatus to 0.01 cfu/m3 and a fourfold decline in aspergillosis incidence during the next 2 years. These findings, together with laboratory studies that showed aspergilli could proliferate on common hospital materials when moistened, indicate a need for careful environmental maintenance.     

Fungal Ascending Aortic Aneurysm after Cardiac Surgery

A 52-year-old diabetic male was admitted due to 1-month history of fever, fatigue, and mild shortness of breath. Three months prior to admission, he had undergone aortic valve replacement, with a prosthetic one, because of streptococcus viridans endocarditis complicated by severe aortic regurgitation. Transesophageal echocardiogram revealed prosthetic valve endocarditis with dehiscence of the aortic valve and an abscess cavity extending from the aortic root into the ascending aorta. Blood cultures and serology were negative. Due to clinical deterioration, despite antibiotic therapy, the patient was reoperated on and the aortic valve and ascending aorta were replaced with a homograft. Valve culture grew Aspergillus flavus. This case is an example of a rare but of increasing frequency complication after cardiac surgery. Considering the high mortality from this complication, early recognition is of paramount importance.     

Increased recovery of Aspergillus flavus from respiratory specimens during hospital construction

An increase in the recovery of Aspergillus flavus from respiratory specimens occurred among hospitalized patients during a several-month period in 1977. Notably, 86% of the patients with positive culture results were located in an older hospital section adjacent to a building construction site that created great amounts of dust in the hospital's vicinity. Airborne contamination was suspected and results of air sampling showed A. flavus in 80% of old wing patient rooms (average, 8 A. flavus/positive room) compared with only 23% of the contiguous newer wing patient rooms (average, 1 A. flavus/positive room). Inspection of the main mechanical ventilation units in the two hospital sections disclosed numerous defects in the unit in the old wing and a properly functioning unit in the new wing. After repairing the defective unit, a significant reduction in the recovery of A. flavus from clinical and environmental specimens was noted.     

Tibial osteomyelitis due toAspergillus flavus in a heart transplant patient

Summary Aspergillus flavus was identified as the causative organism of a case of osteomyelitis involving the proximal epiphysis of the left tibia in a heart transplant patient. History revealed a previous pretibial wound due to a fall in the street as the consequence of a sudden cardiac arrest. Surgical debridement combined with fungostatic treatment including amphotericin B and itraconazole was followed by clinical improvement, although the fungus could still be recovered by culture on subsequent samples.

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Osteomyelitis der Tibia durch Aspergillus flavus bei einem Herztransplantatempfänger

Zusammenfassung Bei einem Herztransplantatempfänger trat eine Osteomyelitis der linken Tibiaepiphyse auf, als deren kausaler ErregerAspergillus flavus identifiziert wurde. Der Patient war bei einem plötzlichen Herzstillstand gefallen und hatte sich eine Wunde im prätibitalen Bereich zugezogen. Nach chirurgischem Debridement und fungostatischer Behandlung mit Amphotericin B und Itraconazol kam es zu einer klinischen Besserung, doch blieben die Pilzkulturen weiterhin positiv.

     

Tuberculous fibrosing mediastinitis: CT and MRI findings.

Fibrosing mediastinitis is a rare entity usually caused by granulomatous disease. Most cases develop as a complication of histoplasmosis. Mediastinal involvement caused by tuberculosis most often produces focally enlarged lymph nodes, with diffuse mediastinal involvement a very unusual manifestation of disease. The authors describe a patient with extensive tuberculous fibrosing mediastinitis, in whom fibrotic masses produced compression of airways and vascular structures with resultant parenchymal changes.     

Superior vena cava syndrome due to chronic granulomatous mediastinitis

We report a case of superior vena cava syndrome developing progressively over twenty years in a 48-year-old Venezuelan woman. The investigations revealed a locoregional etiology for the vena cava obstruction, namely a granulomatous mediastinitis probably secondary to histoplasmosis. We discuss the etiology, the clinical features, the natural course, and the therapy of chronic mediastinitis.     

Inhibition of complement by culture supernatants of Aspergillus fumigatus

Aspergillus fumigatus produced a water-soluble extracellular material that inhibited the opsonization of fungal cells by normal human serum. Blastospores of Cryptococcus neoformans and conidia from A. fumigatus or Aspergillus niger were used as fungal targets for ingestion by human monocytes. The opsonic inhibitor from A. fumigatus was found to decrease binding of complement component C3b to fungal surfaces by selectively interfering with activation of the alternative complement pathway. Inhibition of complement did not appear to result simply from proteolysis, as judged by the minimal degradation of casein and of purified C3 and C4. The complement-inhibiting activity was partially labile to heating at 100 C and could be concentrated by using dialysis tubing with a 10,000-dalton exclusion limit. Aspergillus flavus, which is also a pathogen for humans, also produced this activity; A. niger did not. We speculate that this material may represent a pathogenesis factor for Aspergillus species.