Chest Infections: Fellow Case Report Slide: Chest Infections III |

A Rare Form of Invasive Aspergillus Infection in a Severely Immunocompromised Host FREE TO VIEW

Salim Daouk, MD; Hafiz Abdul Moiz Fakih, MD; Divya Patel, MD
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University of Florida, Gainesville, FL

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):141A. doi:10.1016/j.chest.2016.08.150
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SESSION TITLE: Fellow Case Report Slide: Chest Infections III

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 25, 2016 at 04:30 PM - 05:30 PM

INTRODUCTION: Invasive pulmonary aspergillosis in immunocompromised hosts usually involves the lung parenchyma, but in less than 10% of cases it can involve the tracheobronchial tree leading to Aspergillus tracheobronchitis (AT). Three different forms have been described in the literature: obstructive, ulcerative, and pseudomembranous tracheobronchitis.

CASE PRESENTATION: A 52 year old man presented to the emergency department with 2 months history of fatigue, anorexia, low grade fever, and nonproductive cough. He was diagnosed with B-cell lymphoblastic leukemia and was started on cytoreductive chemotherapy. The patient continued to have low grade fever and green sputum production despite being on cefepime and fluconazole for 15 days. CT of the chest showed stable bibasilar tree-in-bud opacities. Bronchoalveolar lavage (BAL) of the right lower lobe was then obtained, but no organisms were identified on bacterial and fungal stains and cultures. Galactomannan in BAL and serum were negative. However, bronchoscopy also revealed a large nonbleeding ulcer in the bronchus intermedius; endobronchial biopsies were obtained and histopathology revealed narrow 45 degrees branching hyphae. This was suggestive of aspergillus ulcerative tracheobronchitis. He was started on voriconazole and 2 days later he defervesced. 1 week later surveillance bronchoscopy was repeated and showed that the ulcer was stable in size with no necrosis or bleeding.

DISCUSSION: In a review of 156 patients with the diagnosis of AT published by Fernández-Ruizetal in 2012, hematologic malignancies were present in 21.2%, and chronic obstructive pulmonary disease was present in 15.4%. Imaging revealed no relevant findings in 47.4%, and 10 patients had serum galactomannan tested, 4 of which were negative, as seen in our patient.

CONCLUSIONS: Aspergillus tracheobronchitis is a rare form of invasive aspergillus infection that occurs in severely immunocompromised hosts. Per the infectious disease society of America guidelines published in 2008, treatment of Aspergillus tracheobronchitis involves systemic therapy with voriconazole in combination with nebulized amphotericin B for several months.

Reference #1: Walsh TJ et al, Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2008

Reference #2: Fernández-Ruiz M et al, Aspergillus tracheobronchitis: report of 8 cases and review of the literature. Medicine (Baltimore). 2012

DISCLOSURE: The following authors have nothing to disclose: Salim Daouk, Hafiz Abdul Moiz Fakih, Divya Patel

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