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Aspergillus Tracheobronchitis With Endobronchial Obstruction: A Rare but Deadly Complication After Bone Marrow Transplant FREE TO VIEW

Debby Sentana, MD; Junhong Gui, MD; Mohammed Sharif, MD
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Florida Hospital, Orlando, FL

Chest. 2014;146(4_MeetingAbstracts):161A. doi:10.1378/chest.1995234
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

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

INTRODUCTION: Invasive Aspergillosis most commonly occurs in the setting of immunosuppression, and usually involves lung parenchyma. Here we report a rare case of Aspergillus infection causing severe endobronchial obstruction, also known as Aspergillus tracheobronchitis.

CASE PRESENTATION: A 40 year old male with acute myelogenous leukemia (AML) presented with dyspnea and wheezing. He was on immunosuppression after an allogeneic bone marrow transplant (BMT) and steroids for graft-versus-host disease (GVHD) of the skin. CT chest was done, which was suggestive of GVHD. Patient continued to have dyspnea, eventually requiring endotracheal intubation. Bronchoscopy showed significant endobronchial lesions causing severe circumferential narrowing of distal bronchi (see image). Endobronchial biopsy showed inflammatory cells with fungal hyphae consistent with Aspergillus. Endobronchial culture revealed presence of Aspergillus fumigatus. Based on these findings, the diagnosis of endobronchial obstructive Aspergillus tracheobronchitis was made. Patient was started on systemic antifungal therapy, and later received endobronchial amphotericin B injections. However, his condition continued to decline, and eventually withdrawal of care was done.

DISCUSSION: Invasive Aspergillosis commonly affects the immunocompromised population. About 7-10% of invasive Aspergillosis manifest as Aspergillus tracheobronchitis, which is a rare complication after BMT. Aspergillus tracheobronchitis involves the tracheobronchial tree, and causes respiratory failure either by endobronchial obstruction or hemorrhage due to the invasion of the pulmonary vessels. First clinical symptoms present as fever, cough, dyspnea, and wheezing, followed by respiratory failure. Chest radiograph and CT may not reveal pulmonary lesions, and diagnosis requires bronchoscopy with biopsy and cultures. Several risk factors associated with Aspergillus tracheobronchitis include underlying airway disease, prolonged use of endotracheal tube, and decreased mucociliary production. The uses of steroids have been reported as possible risk factor for Aspergillus tracheobronchitis in BMT patients. Our patient was on steroids prior to admission, which may contribute to his risk factor for this disease. Despite the early diagnosis and initiation of antifungal therapy, our patient succumbed to progressive respiratory failure.

CONCLUSIONS: Aspergillus tracheobronchitis with endobronchial obstruction carries poor prognosis. This diagnosis should be considered in BMT patients presenting with respiratory symptoms, and when suspected, bronchoscopy should be done immediately despite normal chest imaging to ensure early diagnosis.

Reference #1: Krenke R, Grabczak E. Tracheobronchial Manifestations of Aspergillus Infections. TheScientificWorldJOURNAL. 2011;11:2310-2329.

Reference #2: Machida U, Kami M, et al. Aspergillus tracheobronchitis after allogeneic bone marrow transplantation. Bone Marrow Transplantation. 1999; 24:1145-1149.

DISCLOSURE: The following authors have nothing to disclose: Debby Sentana, Junhong Gui, Mohammed Sharif

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