Pulmonary Aspergillosis: An Analysis of 41 Patients

doi:10.1016/S0003-4975(10)63943-4

The Annals of Thoracic Surgery

Volume 22, Issue 1, July 1976, Pages 1-7

https://doi.org/10.1016/S0003-4975(10)63943-4 Get rights and content

Abstract

During the period 1969 to 1974, 41 patients having cultures positive for aspergillus were seen on the thoracic surgical services of the University of Maryland and Mt. Wilson State Hospitals. Intracavitary mycetoma was present in 36 patients. In 32 the underlying disease was chronic cavitary tuberculosis, 5 had decreased immunity due to other diseases, and in 3 no underlying disease was noted. One final patient developed a mycetoma following repair of tetralogy of Fallot.

Hemoptysis, the predominant symptom, occurred in 23 patients, all of whom were from the group with intracavitary mycetoma. Hemoptysis was life-threatening in 8 patients, severe but not life-threatening in 12, and minimal in 3. Fifteen patients underwent pulmonary resection with 2 deaths. Both patients who died had undergone emergency resection for life-threatening hemoptysis; the fungus ball had developed following a previous resection for tuberculosis, and both had poor pulmonary reserve. Of 10 patients with hemoptysis who were not treated surgically, chiefly because they were poor operative risks, 4 died.

This study suggests that pulmonary aspergillosis, particularly of the intracavitary type, is a potentially life-threatening disease. Because of the suddenness with which massive hemoptysis may occur, pulmonary resection is recommended for all patients with intracavitary mycetoma who do not constitute prohibitive operative risks.

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Cited by (84)

Bronchoscopic removal of a large intracavitary pulmonary aspergilloma
2013, Chest
Pulmonary aspergilloma is a chronic fungal infection that has a high mortality when hemoptysis occurs. Surgery is the treatment of choice, but patients often have severe physiologic impairment putting them at risk for significant surgical morbidity and mortality. We present the case of a 63-year-old woman with a large aspergilloma, unfit for surgery due to medical reasons. The aspergilloma was enlarging, with progression of the patient's symptoms of anorexia, cough, chest discomfort, and hemoptysis. Bronchoscopy revealed an airway leading into a cavity with a large fungal ball. Biopsy confirmed Aspergillus fumigatus. Using flexible and rigid bronchoscopy, the aspergilloma was mechanically removed. Eighteen months later the patient reported no hemoptysis, reduced pain and cough, significant weight gain, and improved appetite, with no recurrence of the aspergilloma on repeat imaging. To our knowledge, this is the first reported case of bronchoscopic removal of a large cavitary aspergilloma. This important new treatment modality provides a viable alternative therapy for this potentially life-threatening problem.
Pulmonary aspergilloma. Clinical aspects and surgical treatment outcome
2012, Thoracic Surgery Clinics
Indications for Surgery in Patients with Localized Pulmonary Infection
2012, Thoracic Surgery Clinics
Citation Excerpt :
Even lobectomy for aspergilloma, however, is often difficult because of dense vascular adhesions and pleural fibrosis, which result in relatively high intraoperative blood loss and transfusion rates.9,11 The overall operative mortality rates reported for resection of aspergilloma range from 5.6% to 22.6%.9,11–13,16 Even after lobectomy, the potential postoperative complications that contribute to mortality include hemorrhage, empyema, bronchopleural fistula, and respiratory failure.
Place of surgery in pulmonary aspergillosis and other pulmonary mycotic infections
2012, Revue de Pneumologie Clinique
La chirurgie fait partie de la stratégie thérapeutique des infections aspergillaires et des mucormycoses. L’aspergillome se définit comme une masse arrondie pseudotumorale de développement intracavitaire due à la prolifération des spores d’Aspergillus. La complication la plus fréquente est l’hémoptysie rapportée dans 50 à 95 % des cas. Les lésions pleuropulmonaires favorisantes sont : les cavernes tuberculeuses, les poches pleurales résiduelles, les bulles d’emphysème et le poumon détruit après radiothérapie ou fibrose ou bronchectasies. Les indications de la chirurgie dépendent des symptômes, de la fonction respiratoire du patient, de l’état du poumon sous-jacent et du type d’aspergillome (simple ou complexe). Chez un patient porteur d’un aspergillome intrapulmonaire, si les fonctions respiratoires le permettent, une résection pulmonaire sera proposée éventuellement précédée d’une embolisation. Pour les aspergillomes intrapleuraux, la thoracoplastie sera préconisée si l’état général du patient le permet. L’aspergillose pulmonaire invasive (API) se caractérise par une invasion des tissus bronchiques et des vaisseaux par les filaments mycéliens chez des patients ayant une immunosuppression profonde et prolongée. Le taux de décès des patients ayant fait une API après traitement pour une leucémie ou lymphome était de 30 à 40 %, après une greffe de moelle de 60 %, après transplantation de 50 à 60 % et après toute autre cause d’immunosuppression de 70 à 85 %. La principale cause de ces décès est l’hémoptysie massive. La chirurgie (une lobectomie) est indiquée pour la prévention des hémoptysies lorsque la masse aspergillaire se situe au contact de l’artère pulmonaire ou l’une de ses branches et si elle augmente de taille avec la disparition du liseré de sécurité entre la masse et la paroi du vaisseau. Le patient sera opéré en urgence avant que les globules blancs n’atteignent le seuil de 1000 éléments/mm³. Une masse résiduelle persistante après un traitement antifongique peut justifier d’une résection pulmonaire (wedge ou lobectomie) avant la reprise d’une nouvelle thérapeutique agressive. Les mucormycoses surviennent chez des patients immunodéprimés (maladie hématologique, diabètes, transplantation, brûlures, dénutrition). Le traitement d’une mucormycose pulmonaire associe les antifongiques et la résection pulmonaire.
Surgery is part of the therapeutic strategy of aspergillosis and mucormycosis. The aspergilloma is defined as a rounded mass, developing in a cavity by the proliferation of spores of Aspergillus. The most common complication was haemoptysis reported in 50–95% of cases. The pleuropulmonary lesions predisposing are: tuberculosis, residual pleural space, emphysema and lung destroyed by fibrosis or radiotherapy or bronchiectasis. The indications for surgery depend on symptoms, respiratory function, the parenchyma and the type of aspergilloma (simple or complex). In a patient with an intrapulmonary aspergilloma, lung resection preceded by embolization is recommended based on respiratory function. For intrapleural aspergilloma, thoracoplasty is recommended according to the patient's general condition. The invasive pulmonary aspergillosis (IPA) is characterized by an invasion of lung tissue and blood vessels by hyphae in immunocompromised patients. The death rate of patients who have an API after treatment for leukemia or lymphoma was 30 to 40%, after bone marrow transplantation 60%, after solid organ transplantation from 50 to 60% and after any other cause of immunocompromising from 70 to 85%. The main cause of these deaths is massive hemoptysis. Surgery (lobectomy) is indicated for the prevention of hemoptysis when the mass is in contact with the pulmonary artery or one of its branches, and if it increases in size with the disappearance of border security between the mass and the vessel wall. The patient will be operated in an emergency before the white blood cells do not exceed the threshold of 1000 cells/μl. A persistent residual mass after antifungal treatment may justify a lung resection (lobectomy or wedge) before a new aggressive therapy. Mucormycosis affects patients following immunocompromising states — haematologic malignancy, diabetes mellitus, transplantation, burns and malnutrition. The treatment of pulmonary mucormycosis combines surgical and medical approach.
Predictive and prognostic value of preoperative symptoms in the surgical treatment of pulmonary aspergilloma
2010, Journal of Surgical Research
Surgical resection is widely accepted as the treatment of choice for pulmonary aspergilloma (PA). However, the technique involved ranks among the most challenging in thoracic surgery and remains associated with considerable morbidity and mortality. To improve the outcomes, it is essential to establish clear recommendations for optimal timing of surgery and selection of patients. To facilitate this, we analyzed the impact of preoperative clinical factors on the results of treatment.
Medical records of patients treated surgically for PA between 1979 and 2007 were retrospectively reviewed for clinical variables of potential impact on the surgical outcome with emphasis on preoperative symptoms.
Sixty-four patients, including 22 cases of simple aspergilloma and 42 cases of complex aspergilloma were enrolled in the study. Univariable analysis followed by multivariable logistic regression identified weight loss and massive hemoptysis as risk factors for postoperative morbidity [odds ratio (OR) = 8.856, P = 0.006 and OR = 6.9, P = 0.021, respectively]. Ten-year cumulative survival in simple aspergilloma and complex aspergilloma was 88.3% and 70.6%, respectively (P = 0.042). Multivariable analysis by Cox proportional hazard model showed that younger age and lack of massive hemoptysis were independent favorable prognostic factors [hazard ratio (HR) = 1.13, P = 0.0004 and HR = 4.71, P = 0.0319, respectively)
Massive hemoptysis is an independent unfavorable predictive and prognostic factor in the surgical treatment of PA. We believe that in operable cases, early surgical resection may be recommended even in asymptomatic patients. This strategy may prevent development of life-threatening symptoms and offers a realistic chance of permanent cure with acceptable mortality and morbidity.
Surgery for Pulmonary Aspergilloma in Immunocompetent Patients: No Benefit From Adjuvant Antifungal Pharmacotherapy
2010, Annals of Thoracic Surgery
Citation Excerpt :
Surgical resection is regarded as the treatment of choice, particularly in symptomatic patients. Previous series reported mortality rates of up to 43% and morbidity mainly from hemorrhage, bronchopleural fistula, and empyema at rates of up to 60% [10, 22, 35]. Thus, surgery was limited to patients with severe life-threatening symptoms.
The optimal treatment strategy for pulmonary aspergilloma (PA) remains controversial. Among a variety of options, surgical removal of the mycetoma is considered the most effective. However, it ranks among the most challenging procedures and is associated with considerable mortality and morbidity. Previous studies showed that the use of antifungal agents improved outcomes in high-risk surgical patients with mycotic infections. We hypothesized whether combining antifungal pharmacotherapy with surgical resection in patients with PA could yield a strategy more beneficial than surgery alone.
Medical records of 72 patients with PA treated surgically at our department between January 1984 and December 2007, were retrospectively reviewed for clinical variables including adjuvant antifungal pharmacotherapy and the outcomes of treatment.
Ten-year cumulative survival was 74.8% in patients with adjuvant antifungals and 78.9% after surgery alone (p = 0.11). Multivariable analysis by logistic regression model (χ² = 11.41; degrees of freedom = 5; p = 0.043) identified pneumonectomy as a significant risk factor for postoperative morbidity (odds ratio = 6.499; 95% confidence interval 1.388 to 30.423; p = 0.018). Multivariable analysis using the Cox proportional hazard model (χ² = 26.3; degrees of freedom = 7; p = 0.00045) revealed that female gender, forced expiratory volume in 1 second greater than 75%, and simple aspergilloma were independent favorable prognostic factors (hazard ratio = 10.86, p = 0.013; hazard ratio = 13.45, p = 0.004; and hazard ratio = 11.97, p = 0.028, respectively). Neither univariable nor multivariable analysis indicated that antifungals significantly affected morbidity or survival.
Adjuvant antifungal pharmacotherapy appears not to improve the results of surgical treatment for PA, and may cause severe adverse effects. We believe that whenever definitive surgical removal of the mycetoma is feasible, antifungals may not be beneficial.

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: Presented at the Twenty-second Annual Meeting of the Southern Thoracic Surgical Association, Nov 6–8, 1976, New Orleans, LA.

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Pulmonary Aspergillosis: An Analysis of 41 Patients

Abstract

Chest

Chest

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am J Med

Dis Chest

Bronchopulmonary aspergillosis

Am Rev Resp Dis

Secondary aspergillosis

Ann Intern Med

Une nouvelle forme anatomo-radiologique de mycose pulmonaire primitive: le mégamycétome intra bronchiectatique

Arch Med Chir Appar Resp