Affiliations: Drs. Hu and Huang are affiliated with the General Hospital of Guangzhou Military Command.
Correspondence to: Haijian Du, Department of Pulmonology, General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd, Guangzhou 510010, People's Republic of China; e-mail: HJ_DU1@163.com
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).
© 2009 American College of Chest Physicians
We read with interest the article by Sakkour et al1 in CHEST (February 2008), who reported the case of a 56-year-old woman with COPD and multiple pulmonary nodules. We congratulate the authors on finding pulmonary aspergillosis associated with marijuana smoking in a patient without clinical evidence of an immune deficiency. However, two aspects of this report require further discussion.
First, instead of invasive pulmonary aspergillosis (IPA), we believe the precise diagnosis should be chronic necrotizing pulmonary aspergillosis (CNPA). To start with, the patient does not show any clinical symptoms of IPA, nor are her COPD symptoms getting any more severe. The occurrence of IPA in COPD patients will intensify symptoms like shortness of breath. Next, the CT scan of her chest shows no evidence that her left upper lobe nodule is progressing any further. This suggests that the nodule is of a slow progressive nature.
In addition, the findings of the two CT scan-guided biopsies were both nondiagnostic and revealed predominantly fibrous tissue. In clinical practices, the diagnosis of CNPA commonly stands on the presence of multiple cultures that are positive for Aspergillus organisms, chest radiographs with abnormal findings, and test findings for bronchoscopy biopsy specimens that are consistent with tissue invasion.2
Last, the authors' diagnosis rests mainly on the results of a biopsy performed with video-assisted thorascopic surgery, showing caseating granulomas and granulomatous pleuritis, with evidence of Aspergillus species and thrombosed vessels in the center of one of the nodules. However, Yousem3 has also reported 4 of 10 persons with conditions resembling necrotizing granulomatous pneumonia centered around a central zone of infarct-like necrosis of the parenchyma, resulting from angioinvasive Aspergillus. This is incredibly similar to the histopathology reported by Sakkour et al.1
In conclusion, in contrast to IPA, CNPA is a chronic process that progresses slowly over months to years. IPA, on the other hand, is a severe and commonly fatal disease that is seen in immunocompromised patients. Therefore, we incline to believe that the diagnosis in this case should be CNPA.
Second, we totally agree with the authors in regarding marijuana smoking as the main factor for pulmonary aspergillosis in this patient. Nonetheless, we believe that the fluticasone therapy the patient received (since the report did not specify the dosage of fluticasone, we can only take the recommended dosage of fluticasone for a severe pulmonary patient into consideration) is also one of the key factors for the occurrence of pulmonary aspergillosis in this patient. Reports2,4,5 have shown that therapy with not only oral steroids, but also with inhaled steroids might promote IPA or CNPA in COPD patients.
Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
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