SURGICAL INFECTIONS Volume 16, Number 1, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/sur.2014.143
Aortic Graft Infection Caused by Invasive Pulmonary Aspergillosis Hsu-Chung Liu,1–3 Min-Chi Lu,4–6 Yi-Chun Lin,2 Yi-Chyi Lai,4–6 Ming-Shiou Jan,5 Wea-Lung Lin,3,7 and Chuan-Mu Chen 2,8
A
n 83-year-old male presented with blood-tinged sputum and 2-mo recurrent fever. He had hypertension and a Stanford type A aortic dissection that had been repaired by a Dacron (Maquet, Rastatt, Germany) aortic graft repair operation 5 y prior. Chest radiograph and computed tomography (CT) scan revealed multiple pulmonary infiltrates and a
giant cavity abutting the aortic graft (Fig. 1A) that had been absent on a previous CT conducted 1 y prior (Fig. 1B). The giant cavity was formed by an eroding thrombus and air (Fig. 1A). Fiberoptic bronchoscopy revealed a perforation in the apical segmental bronchus of the left lower lobe (Fig. 1C). The bronchoscope tip entered an empty space filled with
FIG. 1. (A) Chest computed tomography (CT) showing a giant cavity (arrowhead) abutting the aortic graft and multiple pulmonary infiltrates (arrow). (B) Comparison of previous chest CT recorded 1 y prior. (C) Bronchoscopic image showing whitish caseous material beneath a bronchial perforation (arrowhead). (D) The bronchial perforation (arrow) was connected to the adjacent aortic graft (arrowhead). 1
Division of Chest Medicine, Department of Internal Medicine, Cheng Ching Hospital, Taichung City, Taiwan, Republic of China. Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung City, Taiwan, Republic of China. 3 School of Medicine, 4Department of Microbiology and Immunology, 5Institute of Microbiology and Immunology, Chung Shan Medical University, Taichung City, Taiwan. 6Division of Infectious Diseases, Department of Internal Medicine, 7Department of Pathology, Chung Shan Medical University Hospital, Taichung City, Taiwan, Republic of China. 8 Rong-Hsing Translational Medical Center, and iEGG Center, National Chung Hsing University, Taichung City, Taiwan, Republic of China. 2
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whitish caseous tissue through the bronchial perforation. The bronchial perforation was observed to be connected to adjacent aortic graft on the chest CT scan (Fig. 1D). A GrocottGomori methenamine silver stain of the biopsy specimen obtained from caseous material beneath the bronchial perforation exhibited numerous septated hyphae. Positive Aspergillus flavus and Mycobacterium tuberculosis cultures were identified in sputum and bronchoalveolar lavage fluid but not in the blood. A culture of the biopsy specimen isolated only A. flavus. Polymerase chain reaction for identifying M. tuberculosis complex in the biopsy specimen yielded a negative result. In addition to active pulmonary tuberculosis, invasive pulmonary aspergillosis associated with an aortic graft infection was diagnosed. The patient exhibited clinical stability with prolonged anti-fungal and anti-tuberculous treatment. However, he died from aspiration pneumonia with respiratory failure 2 mo later. Prosthetic vascular graft infection caused by Aspergillus species is a rare condition. Perigraft air, fluid, soft tissue attenuation, and pseudoaneurysm can be observed by CT scans of patients with aortic graft infection [1]. This patient exhibited an unusual presentation of a cavity within the pre-existing perigraft thrombus. The bronchial perforation, an unusual bronchoscopy finding, has never before been observed in patients with invasive pulmonary aspergillosis [2]. Most cases of vascular graft infection caused by Aspergillus species are believed to originate from contamination by fungal spores during surgery [3–5]. However, surgical contamination was implausible in this patient because its onset was 5 y after surgery. Because Aspergillus species are angioinvasive, the patient could have had a bronchopleural fistula initially and developed the adjacent aortic graft infection subsequently caused by pulmonary aspergillosis. The unique radiologic findings observed in this patient provide new understanding
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for disease manifestations of invasive pulmonary aspergillosis. Acknowledgments
H.C.L. and M.C.L. provided direct patient care. W.L.L. made the pathologic diagnosis. All authors wrote the report. Written consent for publication was obtained. References
1. Orton DF, LeVeen RF, Saigh JA, et al. Aortic prosthetic graft infections: Radiologic manifestations and implications for management. Radiographics 2000;20:977–993. 2. Verea-Hernando H, Martin-Egana MT, Montero-Martinez C, Fontan-Bueso J. Bronchoscopy findings in invasive pulmonary aspergillosis. Thorax 1989;44:822–823. 3. Fuster RG, Clara A, di Stefano S, et al. An unusual vascular graft infection by Aspergillus—A case report and literature review. Angiology 1999;50:169–173. 4. Collazos J, Mayo J, Martinez E, Ibarra S. Prosthetic vascular graft infection due to Aspergillus species: Case report and literature review. Eur J Clin Microbiol Infect Dis 2001;20:414–417. 5. Paterson DL. New clinical presentations of invasive aspergillosis in non-conventional hosts. Clin Microbiol Infect 2004;10(Suppl 1):24–30.
Address correspondence to: Dr. Chuan-Mu Chen Department of Life Sciences Agricultural Biotechnology Center National Chung Hsing University No. 250, Kuo Kuang Rd. Taichung 402 Taiwan, Republic of China E-mail: [email protected]
Aortic Graft Infection Caused by Invasive Pulmonary Aspergillosis Hsu-Chung Liu,1–3 Min-Chi Lu,4–6 Yi-Chun Lin,2 Yi-Chyi Lai,4–6 Ming-Shiou Jan,5 Wea-Lung Lin,3,7 and Chuan-Mu Chen 2,8
A
n 83-year-old male presented with blood-tinged sputum and 2-mo recurrent fever. He had hypertension and a Stanford type A aortic dissection that had been repaired by a Dacron (Maquet, Rastatt, Germany) aortic graft repair operation 5 y prior. Chest radiograph and computed tomography (CT) scan revealed multiple pulmonary infiltrates and a
giant cavity abutting the aortic graft (Fig. 1A) that had been absent on a previous CT conducted 1 y prior (Fig. 1B). The giant cavity was formed by an eroding thrombus and air (Fig. 1A). Fiberoptic bronchoscopy revealed a perforation in the apical segmental bronchus of the left lower lobe (Fig. 1C). The bronchoscope tip entered an empty space filled with
FIG. 1. (A) Chest computed tomography (CT) showing a giant cavity (arrowhead) abutting the aortic graft and multiple pulmonary infiltrates (arrow). (B) Comparison of previous chest CT recorded 1 y prior. (C) Bronchoscopic image showing whitish caseous material beneath a bronchial perforation (arrowhead). (D) The bronchial perforation (arrow) was connected to the adjacent aortic graft (arrowhead). 1
Division of Chest Medicine, Department of Internal Medicine, Cheng Ching Hospital, Taichung City, Taiwan, Republic of China. Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung City, Taiwan, Republic of China. 3 School of Medicine, 4Department of Microbiology and Immunology, 5Institute of Microbiology and Immunology, Chung Shan Medical University, Taichung City, Taiwan. 6Division of Infectious Diseases, Department of Internal Medicine, 7Department of Pathology, Chung Shan Medical University Hospital, Taichung City, Taiwan, Republic of China. 8 Rong-Hsing Translational Medical Center, and iEGG Center, National Chung Hsing University, Taichung City, Taiwan, Republic of China. 2
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GRAFT INFECTION CAUSED BY ASPERGILLOSIS
whitish caseous tissue through the bronchial perforation. The bronchial perforation was observed to be connected to adjacent aortic graft on the chest CT scan (Fig. 1D). A GrocottGomori methenamine silver stain of the biopsy specimen obtained from caseous material beneath the bronchial perforation exhibited numerous septated hyphae. Positive Aspergillus flavus and Mycobacterium tuberculosis cultures were identified in sputum and bronchoalveolar lavage fluid but not in the blood. A culture of the biopsy specimen isolated only A. flavus. Polymerase chain reaction for identifying M. tuberculosis complex in the biopsy specimen yielded a negative result. In addition to active pulmonary tuberculosis, invasive pulmonary aspergillosis associated with an aortic graft infection was diagnosed. The patient exhibited clinical stability with prolonged anti-fungal and anti-tuberculous treatment. However, he died from aspiration pneumonia with respiratory failure 2 mo later. Prosthetic vascular graft infection caused by Aspergillus species is a rare condition. Perigraft air, fluid, soft tissue attenuation, and pseudoaneurysm can be observed by CT scans of patients with aortic graft infection [1]. This patient exhibited an unusual presentation of a cavity within the pre-existing perigraft thrombus. The bronchial perforation, an unusual bronchoscopy finding, has never before been observed in patients with invasive pulmonary aspergillosis [2]. Most cases of vascular graft infection caused by Aspergillus species are believed to originate from contamination by fungal spores during surgery [3–5]. However, surgical contamination was implausible in this patient because its onset was 5 y after surgery. Because Aspergillus species are angioinvasive, the patient could have had a bronchopleural fistula initially and developed the adjacent aortic graft infection subsequently caused by pulmonary aspergillosis. The unique radiologic findings observed in this patient provide new understanding
113
for disease manifestations of invasive pulmonary aspergillosis. Acknowledgments
H.C.L. and M.C.L. provided direct patient care. W.L.L. made the pathologic diagnosis. All authors wrote the report. Written consent for publication was obtained. References
1. Orton DF, LeVeen RF, Saigh JA, et al. Aortic prosthetic graft infections: Radiologic manifestations and implications for management. Radiographics 2000;20:977–993. 2. Verea-Hernando H, Martin-Egana MT, Montero-Martinez C, Fontan-Bueso J. Bronchoscopy findings in invasive pulmonary aspergillosis. Thorax 1989;44:822–823. 3. Fuster RG, Clara A, di Stefano S, et al. An unusual vascular graft infection by Aspergillus—A case report and literature review. Angiology 1999;50:169–173. 4. Collazos J, Mayo J, Martinez E, Ibarra S. Prosthetic vascular graft infection due to Aspergillus species: Case report and literature review. Eur J Clin Microbiol Infect Dis 2001;20:414–417. 5. Paterson DL. New clinical presentations of invasive aspergillosis in non-conventional hosts. Clin Microbiol Infect 2004;10(Suppl 1):24–30.
Address correspondence to: Dr. Chuan-Mu Chen Department of Life Sciences Agricultural Biotechnology Center National Chung Hsing University No. 250, Kuo Kuang Rd. Taichung 402 Taiwan, Republic of China E-mail: [email protected]
