IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES Fulminant Invasive Tracheobronchial Aspergillosis Johanna Temime1, Jihad Mallat1, Nicolas Van Grunderbeeck2, Santiago Gimenez3, and Malcolm Lemyze1 1 Department of Respiratory and Critical Care Medicine, 2Department of Infectious Diseases, and 3Department of Anatomopathology, Schaffner Hospital, Lens, France
Figure 1. Fiber-optic bronchoscopy shows multiple areas of ulceration and necrosis on the tracheobronchial mucosa, with white plaques seemingly stuck to the bronchial wall (left) and a pseudotumoral lesion (right). Figure 3. Grocott stain reveals multiple septate hyphae branched at acute angles, and hyphae grouped in typical Aspergillus conidial heads.
Figure 2. After routine staining with hematoxylin and eosin, the bronchial wall biopsy shows diffuse ulcerative inflammatory tracheobronchitis associated with fungal hyphae with superficial mucosal invasion.
A 55-year-old man with a history of diabetes mellitus and chronic obstructive pulmonary disease treated with inhaled corticosteroids developed severely hypoxemic pneumonia caused by Legionella pneumophila. He was transferred to the intensive care unit on Day 2 because of multiple organ failure. On Day 5, despite all attempts made to improve pulmonary gas exchange, extracorporeal membrane oxygenation was required to keep this patient alive. On Day 6, fiber-optic bronchoscopy revealed severe inflammation, ulceration, necrosis, and pseudotumoral lesions of the bronchial mucosa (Figure 1). Rapid anatomopathological examination of a bronchial biopsy specimen led to a prompt diagnosis of invasive tracheobronchial aspergillosis within 3 hours of bronchoscopy (Figures 2 and 3). Although voriconazole was immediately started, the patient rapidly died of cerebral aspergillosis that caused massive cerebral hemorrhage with temporal herniation.
Am J Respir Crit Care Med Vol 191, Iss 7, pp 848–849, Apr 1, 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1164/rccm.201501-0035IM Internet address: www.atsjournals.org
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American Journal of Respiratory and Critical Care Medicine Volume 191 Number 7 | April 1 2015
IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES Invasive aspergillosis is a life-threatening opportunistic infection that usually occurs in severely immunocompromised patients during the course of a transplantation process or in cancer patients (1). Sepsis-induced immune suppression is a special situation where a previously immunocompetent patient may rapidly become vulnerable, especially in the setting of diabetes mellitus, chronic obstructive pulmonary disease, and mechanical ventilation (2, 3). A high degree of suspicion is mandatory because invasive tracheobronchial aspergillosis may rapidly develop as a fulminant superinfection in critically ill patients that were previously considered immunocompetent. Fiber-optic bronchoscopy combined with an urgent histological examination of the bronchial biopsy can accelerate the diagnosis process. n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Krenke R, Grabczak EM. Tracheobronchial manifestations of Aspergillus infections. ScientificWorldJournal 2011;11: 2310–2329.
2. He H, Jiang S, Zhang L, Sun B, Li F, Zhan Q, Wang C. Aspergillus tracheobronchitis in critically ill patients with chronic obstructive pulmonary diseases. Mycoses 2014;57:473–482. 3. Hartemink KJ, Paul MA, Spijkstra JJ, Girbes AR, Polderman KH. Immunoparalysis as a cause for invasive aspergillosis? Intensive Care Med 2003;29:2068–2071.
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
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Figure 1. Fiber-optic bronchoscopy shows multiple areas of ulceration and necrosis on the tracheobronchial mucosa, with white plaques seemingly stuck to the bronchial wall (left) and a pseudotumoral lesion (right). Figure 3. Grocott stain reveals multiple septate hyphae branched at acute angles, and hyphae grouped in typical Aspergillus conidial heads.
Figure 2. After routine staining with hematoxylin and eosin, the bronchial wall biopsy shows diffuse ulcerative inflammatory tracheobronchitis associated with fungal hyphae with superficial mucosal invasion.
A 55-year-old man with a history of diabetes mellitus and chronic obstructive pulmonary disease treated with inhaled corticosteroids developed severely hypoxemic pneumonia caused by Legionella pneumophila. He was transferred to the intensive care unit on Day 2 because of multiple organ failure. On Day 5, despite all attempts made to improve pulmonary gas exchange, extracorporeal membrane oxygenation was required to keep this patient alive. On Day 6, fiber-optic bronchoscopy revealed severe inflammation, ulceration, necrosis, and pseudotumoral lesions of the bronchial mucosa (Figure 1). Rapid anatomopathological examination of a bronchial biopsy specimen led to a prompt diagnosis of invasive tracheobronchial aspergillosis within 3 hours of bronchoscopy (Figures 2 and 3). Although voriconazole was immediately started, the patient rapidly died of cerebral aspergillosis that caused massive cerebral hemorrhage with temporal herniation.
Am J Respir Crit Care Med Vol 191, Iss 7, pp 848–849, Apr 1, 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1164/rccm.201501-0035IM Internet address: www.atsjournals.org
848
American Journal of Respiratory and Critical Care Medicine Volume 191 Number 7 | April 1 2015
IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES Invasive aspergillosis is a life-threatening opportunistic infection that usually occurs in severely immunocompromised patients during the course of a transplantation process or in cancer patients (1). Sepsis-induced immune suppression is a special situation where a previously immunocompetent patient may rapidly become vulnerable, especially in the setting of diabetes mellitus, chronic obstructive pulmonary disease, and mechanical ventilation (2, 3). A high degree of suspicion is mandatory because invasive tracheobronchial aspergillosis may rapidly develop as a fulminant superinfection in critically ill patients that were previously considered immunocompetent. Fiber-optic bronchoscopy combined with an urgent histological examination of the bronchial biopsy can accelerate the diagnosis process. n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Krenke R, Grabczak EM. Tracheobronchial manifestations of Aspergillus infections. ScientificWorldJournal 2011;11: 2310–2329.
2. He H, Jiang S, Zhang L, Sun B, Li F, Zhan Q, Wang C. Aspergillus tracheobronchitis in critically ill patients with chronic obstructive pulmonary diseases. Mycoses 2014;57:473–482. 3. Hartemink KJ, Paul MA, Spijkstra JJ, Girbes AR, Polderman KH. Immunoparalysis as a cause for invasive aspergillosis? Intensive Care Med 2003;29:2068–2071.
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
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