Aspergillus tracheobronchitis (ATB) is an uncommon invasive fungal infection involving the airways. Reported cases have occurred predominantly in severely immunocompromised patients. We report a galactomannan-negative episode of ATB in a patient with a solid organ tumor, which responded to inhaled and systemic antifungal agents.
A 55-year-old female was diagnosed with metastatic adenocarcinoma three weeks prior to hospitalization. An evaluation thereof failed to identify a primary site. She received carboplatin and docetaxel, corticosteroids and radiation to the thoracic spine. At admission, she had a two day history of fever, worsening dyspnea, hemoptysis and wheezing. Laboratory examination was notable for lymphopenia and thrombocytopenia. A chest CT showed bronchial thickening and scattered areas of ground glass opacities. She failed to respond to inhaled bronchodilators, corticosteroids, platelet transfusion, and antibacterials. Worsening stridor and respiratory failure required support by mechanical ventilation. A bronchoscopy was performed at intubation to rule out an upper airway obstruction (Figure 1). It revealed old blood and diffuse white/yellow cobblestoning lesions as well as bilateral pseudomembranes, one obstructing the lumen of the left mainstem bronchus. Bronchial washings and endobronchial biopsies were positive for Aspergillus fumigatus. Corticosteroids were discontinued and voriconazole started. Over the next five days, the patient had persistent wheezing, elevated peak pressures, and moderate amounts of tenacious secretions. Aerosolized amphotericin was added to her regimen and a bronchoscopy was repeated three days later, showing continued, albeit improved pseudomembranes, but resolution of the obstructive airway lesions (Figure 2). An HIV test was negative. Multiple serum galactomannan antigen tests were negative. The peak inspiratory pressure, which was elevated in the initial days of treatment, subsequently fell to much lower values indicating improved lung compliance.
ATB is an uncommon infection that occurs in two distinct patterns. The first is characterized by one or more discrete plaques localized to small portions of the tracheobronchial tree, which may invade the adjacent lung parenchyma and cause focal pneumonia or abscess formation. In the other pattern, which is characteristic of this patient, Aspergillus growth is limited to the intraluminal area with only superficial mucosal invasion and a fibrinopurulent membrane. Most reported cases of ATB have been attributed to the profound immunosuppression associated with bone marrow transplantation (BMT), solid organ transplantation, hematological malignancies, and HIV disease. Other risk factors for this infection in non-BMT patients may include use of high-dose corticosteroids or marijuana. Clinical features are non-specific and may include fever, non-productive cough and, when airway obstruction is present, wheezing. Airway obstruction may be secondary to inflammation, mucus or to fungal pseudomembranes. Chest radiography is typically not helpful and most cases are diagnosed by bronchoscopy. Mortality for ATB is as high as 80%. The most common treatment modalities include amphotericin B, administered systemically or via aerosol, as well as oral itraconazole and voriconazole. In addition, some have supported the use of GM-CSF and gamma interferon. This case illustrates three points. First, our observations do not support previous reports suggesting that serum galactomannan is helpful in both establishing the diagnosis of ATB and monitoring response to therapy (1). Second, monitoring peak inspiratory pressure, once the diagnosis of ATB has been established, can be used to evaluate treatment response. In this patient, improvements in peak inspiratory pressure roughly paralleled clinical improvement seen on fiberoptic bronchoscopy. Finally, inhaled amphotericin, in addition to systemic antifungal therapy, may be helpful.
This case illustrates a patient with galactomannan-negative aspergillus tracheobronchitis. There appears to be a role for aerosolized amphotericin in addition to systemic antifungal therapy. Peak inspiratory pressures can be used to follow clinical response.
A.A. Elshinawy, None.