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Use of Galactomannan to Guide Treatment of Complex Aspergilloma FREE TO VIEW

Jo Henderson-Frost, BA; Marta Feldmesser, MD; Jody Kaban, MD
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Albert Einstein College of Medicine, Bronx, NY

Chest. 2014;146(4_MeetingAbstracts):358A. doi:10.1378/chest.1991745
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SESSION TITLE: Surgery Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: We report a case of a pulmonary aspergilloma managed with right upper lobectomy and adjuvant perioperative antifungal therapy.

CASE PRESENTATION: A 45-year-old Ecuadorian male with a history of tuberculosis at age 20, multiple pneumonias, and right-sided pneumothorax requiring thoracotomy at age 27 was admitted with recurrent hemoptysis and subjective fevers and chills for several months. Chest CT revealed right upper lobe bronchiectasis, bullous disease, and scarring with a 3cm ball highly suspicious for aspergilloma (Fig 1, 2). Sputum specimens were AFB smear and culture negative. Aspergillus antibodies were undetectable in serum. Serum galactomannan (GM) indices performed two weeks apart were 0.97 and 1.04. We performed a lobectomy with rotational flaps to obliterate residual dead space, and because of concern for subacute invasive disease, we treated the patient with oral voriconazole for 4 weeks pre- and post-operatively.

DISCUSSION: Surgical resection is the mainstay of treatment to prevent life-threatening hemoptysis in pulmonary aspergillomas, but is associated with significant post-operative morbidity in complex cases due to the involvement of surrounding lung parenchyma and pleura [1]. The role of adjuvant antifungal therapy has not been well studied for the treatment of aspergillomas in immunocompetent patients. Recent retrospective surgical studies show a variety of antifungal treatment regimens in heterogeneous patient populations [2,3]. Galactomannan, an Aspergillus polysaccharide detectable in serum or bronchoalveolar lavage fluid, is a biomarker suggestive of invasive aspergillosis [1]. The implications of a positive GM assay for surgical and antifungal management are poorly characterized. Prospective studies are needed to evaluate the role of antifungal therapy in reducing post-operative morbidity, and, if beneficial, to define optimal antifungal regimens.

CONCLUSIONS: We report a complex aspergilloma where serum GM indices were consistent with subacute invasive aspergillosis and influenced decisions regarding adjuvant antifungal therapy. GM assays may be useful for determining which patients require antifungal treatment prior to surgical resection of aspergillomas.

Reference #1: Walsh TJ, Anaissie EJ, Denning DW, et al: Treatment of aspergillosis: Clinical practice guidelines of the Infectious Diseases Society of America. Clinical Infectious Diseases 2008; 46:327-60.

Reference #2: Muniappan A, Tapias LF, Butala P, et al: Surgical therapy of pulmonary aspergillomas: A 30-year North American experience. Annals of Thoracic Surgery 2014; 97:432-8.

Reference #3: Farid S, Mohamed S, Devbhandari M, et al: Results of surgery for chronic pulmonary aspergillosis, optimal antifungal therapy and proposed high risk factors for recurrence - a National Centre’s experience. Journal of Cardiothoracic Surgery 2013; 8:180.

DISCLOSURE: The following authors have nothing to disclose: Jo Henderson-Frost, Marta Feldmesser, Jody Kaban

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