SESSION TITLE: Chest Infections II: Student Resident Case Report Posters
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Isolated invasive Aspergillus tracheobronchitis (ATB) is an uncommon clinical form of invasive pulmonary Aspergillosis (IPA) in which Aspergillus infection is limited entirely or predominantly to the tracheobronchial tree. Only a few cases of isolated invasive ATB associated with systemic lupus erythematosus (SLE) have been described in the literature. We report a patient with recently diagnosed SLE, who was found to have isolated invasive ATB and treated successfully with Voriconazole.
CASE PRESENTATION: A 44-year-old woman diagnosed with SLE three months prior was evaluated for chronic dry cough of more than two months duration. Her past medical history included a recent diagnosis of CMV pneumonitis for which she was taking a therapeutic dose of Valganciclovir. Initial physical examination including the examination of chest was unremarkable. Chest imaging with an X-ray and computed tomography did not show any airway or lung parenchymal abnormalities. A bronchoscopic examination performed later showed multiple small sized nodules with superficial ulceration in the trachea and bronchi. Endobronchial biopsies of these nodules were performed and histopathological examination disclosed mucosal accumulation of the chronic inflammatory cells. Special fungal staining further showed septate fungal hyphae compatible with Aspergillus species. Cultures of sputum, bronchial aspirate, and biopsy specimens all grew Aspergillus fumigatus, confirming the diagnosis of isolated invasive ATB. Our patient was started on oral Voriconzaole and a follow up bronchoscopic examination at 3 months showed no gross evidence of residual Aspergillus infection.
DISCUSSION: Invasive aspergillosis more commonly occurs in patients with hematological and other malignancies (often following bone marrow transplantation), AIDS, immunosuppression from chronic corticosteroid therapy, or after solid organ transplantation. Its nonspecific clinical presentation includes fever and respiratory symptoms (cough, wheezing or stridor), and initial radiographic examination lacks sensitivity for early diagnosis. Blood cultures are usually negative, and positive sputum cultures are often considered to represent contamination or colonization. In patients with a high index of suspicion, bronchoscopy with cytology and cultures from bronchoalveolar lavage have been shown to be >90% specific. Voriconazole is currently the first-line agent for the treatment of invasive aspergillosis.
CONCLUSIONS: Isolated invasive ATB may be an early stage of Aspergillus invasion and it may progress to more extensive and invasive infection if early diagnosis is not established. Given the nonspecific and variable clinical presentation, clinicians should be aware of this rare entity in select patient population so that early antifungal therapy can be initiated to halt the progression to more invasive disease.
Reference #1: Ahn MI, Park SH, Kim JA et al. Pseudomembranous necrotizing bronchial aspergillosis. Br J Radiol. 2000;73:73Y75.
DISCLOSURE: The following authors have nothing to disclose: Muhammad Khawar, Muhammad Ishaq, Kellie Jones
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