~~~~~~~~ "
~ SCIE CE
I CASE REPORT I
Aspergillosis of the Lung
Presenting as Hemoptysis
R. L. Gupta, N. Saxena, Sharad Kumar, Monika Mahajan
Abstract
Among mycotic diseases of the lung, pulmonary aspergillosis caused by aspergilloma fumigatlls is
the one encountered most frequently. An unusual case with a cystic lesion in thc lung which turned
out to be an aspergilloma is presented here.
KeyWords
Aspergilloma, Haemoptysis, Fungus infections.
Introd uction
Pulmonary Aspergillosis is commonly prcsent in loss of weight. She had past history of pulmonary Koch's
paticnts who are immunosuppressed or have chronic Iljng 12 years ago and had received a full course of
discases. Majority of these patients present witli antitubercular therapy.
hemoptysis. Although a routine chest radiograph may
She was investigated for the cause of hemoptysis.
suggest the diagnosis ofaspergillosis, CT scan is the best
Routine blood investigations like Hemogram. blood urea,
investigation to confirm it and plan the extent of surgery.
sugar, liver function tests were within normal limits
Operative resseclion is the best modal ity of treatment
except a raised ESR (60 mm in Ist hr.). Sputum for AFB
as it offers permanent cure and avoids any need fOr
was negative. Chest x-ray revealed a cavity in the right
antifungal therapy.
perihilar region with an eccentric soft density mass in i~
Case Report suggesting a possibility of hydatid cyst or a fungal
infection.
A 30 year old lady presented with complaints of
hemoptysis for last 12 years. This was occasional i. e. Bronchoscopy did not reveal any growth but fresh
once in 3-4 months. She had no other associated bleeding was spotted from the opening of superior
complaints like chest pain, breathlessness. There was segment of right lower lobe. Bronchial aspirate and
no history of fever, nausea, vomiting, loss of appetite or sputum were negative for AFB, malignant cells and
From the Department of Surgery, University College of Medical Sciences and associated G. T. B. Hospital. Delhi - 110095
Correspondence to : Dr. R. L. Gupta. Proressor & Consultant, Dcpanl11ent or Surgery, UCMS & GTB IlospitaL Delhi - 110095.
48 Vol. 2 No. I. January-March 2000
•
... l':/K
'_/r:[
SCIENCE
;us. CT scan of the chest revealed a right sided
,riorly placed irregular thick walled cavity at hilar
,I having a dependent sol id component that changed
lion with change in posture. Other lung fields were
I and there was no mediastinal Iymhadenopathy
.1)
Fig. 2. Showing excised specimen of the
Discussion
Aspergillosis is a fungal infection usually caused by
aspergillus fumigatus. Two forms of aspergillosis are
recognised-primary and secondary. Secondary occurs in
damaged lungs or in lungs of host with impaired defence
Contrast enhanced CT scan chest showing irregular thick
walled cavity at hilar level in the posterior segment of mechanisms due to AIDS, malignant disease such as
righllung.
leukaemia or lymphoma or to therapeutic agents such as
The patient was taken up for surgery after steroids, anti-metabolites, cytotoxic drugs, antibiotics or
n,esligations. A right posterolateral thoractomy other drugs causing bone marrow depression (1,2,3).
"as performed lirrough the 5th intercostal space. More frequently,' it occurs in chronic lung disease as a
The lung surface appeared normal in appearance. saprophytic coloniser of pre-existing cavities e. g. caused
On palpation, there was a thickening in the upper by tuberculosis, bronchiectasis etc. (4,5). Aspergillomas
poslerior part of lower lobe. Lung tissue was incised at commonly grow in tuberculous cavities. A British
he site and it revealed a cyst like struCture unlike a Tuberculosis Association report (4) states that
)datidcyst,approximately 5 cm in diameter, which was aspergillomas occur in 15% of open negative cavities
excised (Fig. 2). Hemostasis was ensured and air leaks larger than 2.5 cm with the highest incidence in cavities
"ere sulured and chest was closed with an intercostal of seven to eleven years duration. North American series
lube drainage.Yost operative recovery was uneventful have less incidence of tuberculosis (33%) as reported
and chest tube was removed on the 5th day. The by Faulkner and Colleagues (6) and there, aspergillosis
hislOpathology showed the removed cyst to be an is seen most comonly in association with histoplasmosis
aspergilloma. Subsequently in 5 years follow-up, the (19%), sarcoidosis and ankylosing spondylitis (7). Pleural
atient has had no hemoptysis and is absolutely aspergillomas most often develop in a residual pleural
'l'ryrIJ!omatic. space after operation (or formerly after collapse therapy
Vol. 2No. I. January:March 2000 49
----------iol:,.:;.. \",JK SCIENCE
for tuberculosis) and is favoured by a bronchopleural are confined to a single lobe and if the functl!
fistula (8). and nutritional status of the patient are con,i,,-
The predominant symptoms of aspergillosis are with a major surgical procedure. In all ot\
hemoptysis, bronchorrhoea, fever and weight loss. cases a pleuropneumonectomy for removal ol~,
Hemoptysis occurs in 50 to 80% of patients (1,9). It can mycetoma followed by immediate thoracoplastj
be so severe as to be fatal and therefore aspergillomas recommended (20-21). The most appropriate precedu.
are best treated surgically (10). recommended for aspergillus empyema is a gener
thoracoplasty (20).
Diagnosis is based on repeated isolation of the fungus
In asymptomatic patients mortality rates are 10w(1~
from the sputum (II), transbronchial lavage or biopsy,
as reported by Daly el. af. (17). Such patients shoula
chest x-ray, CT scan, complement fixation test and
undergo operation on principle. The ideal procedureil
aspergillus skin test. Chest x-ray shows an air crescent
segmental or lobar resection (20). Lobectomy is t\e
sign that is a cavity with an eccentric shadow of a fungus
preferred procedure. Pneumonectomy has been donef~
ball (mycetoma) in it (12). Similar appearance is seen
widespread disease (1). The extent of resection of
on a CT scan which is good for localisation and
intrapulmonary aspergilloma depends on the severity of
determining the surgical approach (13). Differential
the underlying lung pathology as well as the aspergilloma
diagnosis includes intracavitary blood clots, liquefying
itself (22). Because of the saprophytic nature of the
pulmonary infection and hydatid cyst (14).
organism, resection should be limited so as not to
Treatment of pulmonary or pleural aspergilloma is decrease lung function but since the organism can be
primarily surgical. The surgical mortality is low (less invasive, a segmental or wedge resection Can sometimes
than 7%) as reported by Kilman (15), potential for cure be dangerous (16).
is excellent and the danger of antifungal chemotherapy
There is .no alternative to operative treatment.
is obviated. Surgery is recommended when the following
Systemic administration'of amphotericin-B or
criteria are satisfied (16) :-
itraconazole (23) is currently beneficial only for invasive
I. Aspergilloma and underlying lung disease are aspergillosis. It has a questionable action on the
not widespread. mycetoma. Di rect intracavitary insti lIation ofantifungal
2. Patient has recurrent episodes of hemoptysis or agents such as amphotericin B, sodium iodide should be
chronic production of purulent sputum. resorted to as primary therapy in patients whose general
3. Patients is in good health. medical status or poor pulmonary. reserve makes the
Mortality rates are high (38-44%) when operating on operative risk prohibitive (24).
symptomatic patients specially whel~ functional and References
I. Eastridge LE, Young JM, Cole F el. al. Pulmonary
nutritional status of the patients are bad (17-19). Aspergillosis. Ann ThoracSurg 1972; 13: 397.
However, operation is advised because symptomatic 2. Symmers WS. Histopathologic aspects of the pathogenesis
of some opportunistic fungal infections as exemplified in
manifestations may become life threatening. A segmental
the pathology ofaspergillosis and phycomycetosis. Lab Invest
or lobar resection may be attempted only if the lesions 1962: It : 1073.
50 Vol. 2 No. I. January·March 2000
i------------.~:r scm CE
Addrizzo-Harris DJ. I-larkin TJ et. al. Pulmonary 15. Kilman JW, Ahn C. Andrews C et. 01. Surgery for
aspergilloma and AIDS. Chest 1997 : 111 (3) : 612-8. pulmonary aspergillosis. J Thorac Cardiovase Sllrg 1969 :
57 : 642.
The Research Committee of the British Tuberculosis
Association. Aspergillus in persistent lung cavities artcr 16. Shirakusa 1'. Ueda 1-1. Suto Tel. 01. Surgical treatment of
tuberculosis. Tubercle 1968: 49 ; I. pulmonary aspcrgilloma and Aspergillus empyema. Ann
Thorae Sllrg 1989 ; 48 : 779-82.
Carbone PP. Seymour MS. Sidramsky H el. 01. Secondary
aspergillosis. AI1/1 Intem Med 1964 ; 50 : 556. 17. Daly PC. Pairolero PC el. 01. Pulmonary aspergilloma.
Results of surgical treatment. J Thorae Cardivasc Surg
6. Faulkner SL. Vernon R. Brown PI'. Fisher RD. Bender HW. 1986: 92: 981-8.
Hemoptysis and pulmonary aspergilloma operative
versus nonoperative trealment. Ann Thorae 511rg 1978 : 18. Jewkes 1. Kay PH. Panelh M. Cilron KM.
25: 389-92. Pulmonary aspergilloma. analysis of prognosis in rclaltion
to hemoptysis and survey of treatment. Thorax 1983 ;
7. Tomlinson JR. Sahn SA. Aspcrgilloma in sarcoid and 38 : 572-8.
tuberculosis. Chest 1987 : 92 : 505-8.
19. Henderson RD, Deslauriers J. Ritcey EL. Delaruc NC.
8 Krakowka P. Rowinska E. Halweg H. Infection orthe pleura Pearson FG. Surgery in pulmonary aspergillosis. J Thorae
by aspergillus fumigatus. Thorax 1970; 25 : 245-53. . CardiovascSurg 1975: 70: 1088-92.
9. Aslam PA. Eastridge CEo Hughes FA. Aspergillosis of the 20. Massard G, Roeslin N. Jeen MW el. aJ. Pleuropulmonary
lung: an eighteen year experience. Chest 1971 : 59 : 28. aspergilloma, clinical spectrum and results of surgical
treatment. Ann Thorac Surg 1992 : 54 (6) : 1159-64.
10. Karas A. Hankins JR. Pulmonary aspergilloma. an analysis
of 41 palients. Anll Thorac SlIrg 1976 : 22 : 1-7. 21. Horio H. Nomori H. Hasegawa T. Cavernostomy.
thoracoplasty for pulmonary aspergilloma. Kyobll-Geka
II. Treger TR, Visscher OW et. al. Diagnosis of pulmonary 1997: 50 (5) : 377-80.
infection caused by aspcrgi lIus. Usefulness of respiratory
22. Garvey J. Crastnopol P. Weiol D el. 01. The surgical treatment
cultures. J IIIJect Dis 1985 : 152 : 572.
of pulmonary aspergillomas. J Thorae Cardiovose SlIrg
12. Scgrelain G. Pulmonary aspergillosis. Lab Invest 1962 ; II : 1977: 74: 542-7.
1047.
23. Jennings TS el. 01. Treatment of aspergillosis with
13. Roberts CM. Citron KM. Stricklend B. Intrathoracic itraconazole. An" Pharmacolher 1993 : 27{ I0) :
aspcrgilloma. Role ofeT in diagnosis and treatment. Radiol 1206-11.
1987: 165: 123-8.
24. Shapiro MJ. Albeda SM el. 01. Severe hemoptysis associated
14 Irwin A. Radiology of the aspcrgilloma. C/in Radial 1966 : with pulmonary aspergilloma. Percutaneous intracavitary
18: 432. trcalment. Chest 1988: 94 : 1225-31.
NOZCON - 2000
Annual Conference
INTERNATIONAL COLLEGE OF SURGEONS
INDIAN SECTION-NORTH ZONE
in collaboration with
REGIONAL SURGEONS ASSOCIATION
JAMMU (J&K), INDIA. 7TH & 8TH APRIL, 2000
Address for correspondence :
Dr. R. K. Chrungoo, 60, Mohinder Nagar, Canal Road, Jammu J&K-180001, Tel: 0191-555373
Dr S· S. Pathania, 21, ND Gandhi Nagar, Jammu J&K-180004. Tel: 0191-432298 Fax: 0191-454041, E-mail:nozcon@grabmail.com
\'01. 2No.1. January-March 2000 51