Pleural
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HUBERT
C. MEREDITH,’
Aspergillosis
BRAD
M. COGAN,1
of aspergillus,
Pleural aspergillosis is an uncommon disease; only 25 cases have been reported in the literature [1]. Two additional patients are described. The disease complicated a preexisting chronic empyema in one, and in the other the pleural cavity was seeded by rupture of an aspemgilloma cavity at the time of pneumonectomy. Case Case
portion invasion
showing
superficial
of the underlying into blood vessels
Reports
white
aspergilloma
of
male underwent the
left
lung
of the pulmo-
,
a left pneumonectomy
apex,
bronchiectasis,
films
showed
evidence
of increasing
and
involvement
Received May 5, 1977; accepted after revision August 19, 1977. ‘Department of Radiology, Medical University of South Carolina, H. C. Meredith. 2Department of Pathology, Medical University of South Carolina, © 1978 American
the necrotic
Pleural thickening has been described as an early manifestation of pulmonary aspergillosis [2], but pleural aspergillosis is not characteristically associated with pulmonary aspengillosis in either its allergic, bronchopneumonic, on intracavitary forms [1]. It has also not been described in the opportunistic setting. In a series of 98 such patients mainly with lymphometicular on hematopoietic malignancies, the pleura was not involved, although the lungs were involved in oven 90% and in many the disease was invasive and widespread [3]. Pleural aspergillosis is known to cause significant clinical manifestations in some patients [1, 4, 5]. In other patients, the organism has been isolated from the pleural cavity together with other organisms such as Staphylococcus aureus Klebsie!la , and Pseudomonas aeruginosa. In some of these patients its presence may have been an incidental finding. In two patients it has been associated with active tuberculous empyema [6]. Among the described cases of pleural aspergillosis [1], etiologic factors include: preexisting pulmonary tuberculosis, 87%; bronchopleumal fistula, 74%; pleural intubation or drainage, 56%; and lung resection, 17%. In most patients multiple antibiotic therapy was administemed. The disease occurred most commonly in patients with an established empyema and a bronchopleunal on pleumocutaneous fistula [6]. The presence of a necrotic exudate and an aerobic environment provide conditions in which the organism may thrive. In one patient, the pleura was seeded by rupture of an aspergilloma cavity during lung resection [1]. This patient also developed osteomyelitis by direct spread of the infection from the pleura. Our two patients, however, demonstrate that the intact pleura may have a capacity to limit the infection. The diagnosis of pleural aspergillosis is established by demonstration of the organism in pleural discharge or by pleural biopsy. Antibodies may also be demonstrated by serological tests. Characteristic radiographic appearances have not been described. Aspergillomas within empyema cavities have been described in only
of the residual left pleural cavity by Aspergillus fumigatus (fig. 2.4). Because of the patient’s condition, the extensive chemotherapy required for obliteration of this organism was not undertaken. His deteriorating course was complicated by renal failure, cirrhosis, and coronary artery disease. He died 3 months after the surgical procedure. At autopsy the left pleural cavity was covered by a blanket of fuzzy green fungus which nested on a layer of necrotic debris overlying a markedly fibrotic pleura. Sections of the pleural cavity demonstrated massive growth of hyphae characteristic
Am J Ro.ntg.nol
into
Discussion
2
and chest
invasion
dense fibrous pleura (fig. 28). No or lymph vessels was found . At the
ficiency secondary to marked chronic inflammation remaining right lung plus foci of acute pneumonia and nary hemorrhage.
organizing pneumonia with abscess. The postoperative course was complicated by episodes of respiratory failure, cardiac arrhythmias, and multiple episodes of aspiration of gastric content, finally controlled by a feeding jejunostomy. Pneumonia and episodes of sepsis were treated. Repeated pleural aspiration
McLAULIN2
1
A 72-year-old for
BRYCE
site of the drainage tube, the tenth rib and costal cartilage were invaded by the organism. The patient died of respiratory insuf-
A 56-year-old black male with a 10 year history of left puimonary atelectasis and pneumothorax was thought to have had a chronic bronchopleural fistula. He had been asymptomatic until 1 year ago when he was hospitalized for a persistent productive cough and fever. A left pyopneumothorax was found which showed gram-positive cocci but no acid-fast bacilli. The empyema was drained, and following a course of antibiotics his symptoms subsided and the chest tube was removed (fig. 1A). He remained well until 1 week prior to this admission when he developed a productive cough, thick yellow sputum, mild dyspnea, night sweats, myalgias, arthralgias, and a malodorous breath. The admission film is shown in figure lB. Thoracentesis revealed a profusion of Aspergi!lus fumigatus together with Serratia marscescens. Pleural biopsy showed evidence of organizing suppurative senositis consistent with empyema, but no evidence of invasion by aspergillosis. No acid-fast bacilli were found, and blood cultures were negative. Following chest drainage and treatment with antibiotics, including amphotenicin B, the pleural infection improved; he underwent a two-stage thoracoplasty, left pneumonectomy, and decortication. The excised ribs showed no evidence of osteomyelitis. The left lung showed fibrosis and organizing pneumonia, while the pleura showed granulation tissue but no evidence of fungus. Case
AND
130:164-166, January Roentgen Ray Society
1978
171 Ashley Avenue, Charleston,
164
Charleston,
South Carolina
South Carolina
29403.
Address
reprint
requests
29403.
0361 -803X/78/01
00-01
64 $02.00
to
Downloaded from www.ajronline.org by 110.38.221.172 on 11/11/15 from IP address 110.38.221.172. Copyright ARRS. For personal use only; all rights reserved
CASE
Fig. 1 -Case film
12 months
1 . A, Frontal later
showing
chest film showing thickened
pleura
chronic
with
left pneumothorax
shaggy
inner
margin.
165
REPORTS
Note
with partial fluid level
atelectasis in left chest
of left lung and pleural and increased atelectasis
-
Fig. 2.-Case 2. A, Frontal chest film after pneumonectomy showing considerable section through pleura showing superficial nature of aspergillosis infection without fungi , Grocott modification, x 200.
two patients [6]. Our radiologic appearance, bordered by a shaggy thickening
has
not
been
two patients with marked inner margin. a feature
showed a similar pleural thickening However, pleural
in all
reported
cases.
thickening deeper
In treating
B have infusion, required
of left pleura
invasion
the
been but to
of the
disease
used
both
treatment sterilize
:
*.
with shaggy inner margin. B, Magnified thickened pleura. Gomori preparation for
[1],
nystatin
parenterally over
the
thickening. B, Admission of left lung.
pleura.
and
and
several An
amphotericin
by intrapleural
months experimental
is
often oral
166
CASE
preparation (BAY b 5097) has been reported effective and nontoxic [7]. Surgical removal of aspemgiliosis-infected pleura and adjacent pulmonary disease provided an effective cure in 10 patients [1].
REPORTS 3. Young AC, Bennett JE, Aspengillosis. Medicine 4. Barlow D: Aspergillosis sis. Proc R Soc Med 47 5.
Downloaded from www.ajronline.org by 110.38.221.172 on 11/11/15 from IP address 110.38.221.172. Copyright ARRS. For personal use only; all rights reserved
REFERENCES 1 . Herring
M, Pecora D: Pleural aspergillosis: 42 :300-302, 1976 2. Libshitz HI, Atkinson GW, Israel HL: Pleural manifestation of aspergillus supeninfection. genol 120 : 883-886, 1974
a case report.
Am Surg
thickening Am
W,
fumigatus
jako
Piotrowski
A,
Kryszkiewicz
T:
Aspergillus
przyczyna powiklania pooperayjnego (Aspergillus fumigatus as the cause of postoperative complications). Gruzlica 27 : 1069, 1959 6. Krakowka P, Aowinska E, Haiweg H: Infection of the pleura
as a
J Roent-
Sitkowski
Vogel CL, Carbone PP, Devita VT: 49 : 147-1 71 , 1970 complicating pulmonary tuberculo: 877, 1954
7.
byAspergillus fumigatus. Thorax 25 : 245-253, 1970 Tardieu P, Diedonne P, Monod 0, Atchoanena JB: Aspergillomes pleuraux. J Franc Med Chir Thor 18 : 591 , 1964
Downloaded from www.ajronline.org by 110.38.221.172 on 11/11/15 from IP address 110.38.221.172. Copyright ARRS. For personal use only; all rights reserved
HUBERT
C. MEREDITH,’
Aspergillosis
BRAD
M. COGAN,1
of aspergillus,
Pleural aspergillosis is an uncommon disease; only 25 cases have been reported in the literature [1]. Two additional patients are described. The disease complicated a preexisting chronic empyema in one, and in the other the pleural cavity was seeded by rupture of an aspemgilloma cavity at the time of pneumonectomy. Case Case
portion invasion
showing
superficial
of the underlying into blood vessels
Reports
white
aspergilloma
of
male underwent the
left
lung
of the pulmo-
,
a left pneumonectomy
apex,
bronchiectasis,
films
showed
evidence
of increasing
and
involvement
Received May 5, 1977; accepted after revision August 19, 1977. ‘Department of Radiology, Medical University of South Carolina, H. C. Meredith. 2Department of Pathology, Medical University of South Carolina, © 1978 American
the necrotic
Pleural thickening has been described as an early manifestation of pulmonary aspergillosis [2], but pleural aspergillosis is not characteristically associated with pulmonary aspengillosis in either its allergic, bronchopneumonic, on intracavitary forms [1]. It has also not been described in the opportunistic setting. In a series of 98 such patients mainly with lymphometicular on hematopoietic malignancies, the pleura was not involved, although the lungs were involved in oven 90% and in many the disease was invasive and widespread [3]. Pleural aspergillosis is known to cause significant clinical manifestations in some patients [1, 4, 5]. In other patients, the organism has been isolated from the pleural cavity together with other organisms such as Staphylococcus aureus Klebsie!la , and Pseudomonas aeruginosa. In some of these patients its presence may have been an incidental finding. In two patients it has been associated with active tuberculous empyema [6]. Among the described cases of pleural aspergillosis [1], etiologic factors include: preexisting pulmonary tuberculosis, 87%; bronchopleumal fistula, 74%; pleural intubation or drainage, 56%; and lung resection, 17%. In most patients multiple antibiotic therapy was administemed. The disease occurred most commonly in patients with an established empyema and a bronchopleunal on pleumocutaneous fistula [6]. The presence of a necrotic exudate and an aerobic environment provide conditions in which the organism may thrive. In one patient, the pleura was seeded by rupture of an aspergilloma cavity during lung resection [1]. This patient also developed osteomyelitis by direct spread of the infection from the pleura. Our two patients, however, demonstrate that the intact pleura may have a capacity to limit the infection. The diagnosis of pleural aspergillosis is established by demonstration of the organism in pleural discharge or by pleural biopsy. Antibodies may also be demonstrated by serological tests. Characteristic radiographic appearances have not been described. Aspergillomas within empyema cavities have been described in only
of the residual left pleural cavity by Aspergillus fumigatus (fig. 2.4). Because of the patient’s condition, the extensive chemotherapy required for obliteration of this organism was not undertaken. His deteriorating course was complicated by renal failure, cirrhosis, and coronary artery disease. He died 3 months after the surgical procedure. At autopsy the left pleural cavity was covered by a blanket of fuzzy green fungus which nested on a layer of necrotic debris overlying a markedly fibrotic pleura. Sections of the pleural cavity demonstrated massive growth of hyphae characteristic
Am J Ro.ntg.nol
into
Discussion
2
and chest
invasion
dense fibrous pleura (fig. 28). No or lymph vessels was found . At the
ficiency secondary to marked chronic inflammation remaining right lung plus foci of acute pneumonia and nary hemorrhage.
organizing pneumonia with abscess. The postoperative course was complicated by episodes of respiratory failure, cardiac arrhythmias, and multiple episodes of aspiration of gastric content, finally controlled by a feeding jejunostomy. Pneumonia and episodes of sepsis were treated. Repeated pleural aspiration
McLAULIN2
1
A 72-year-old for
BRYCE
site of the drainage tube, the tenth rib and costal cartilage were invaded by the organism. The patient died of respiratory insuf-
A 56-year-old black male with a 10 year history of left puimonary atelectasis and pneumothorax was thought to have had a chronic bronchopleural fistula. He had been asymptomatic until 1 year ago when he was hospitalized for a persistent productive cough and fever. A left pyopneumothorax was found which showed gram-positive cocci but no acid-fast bacilli. The empyema was drained, and following a course of antibiotics his symptoms subsided and the chest tube was removed (fig. 1A). He remained well until 1 week prior to this admission when he developed a productive cough, thick yellow sputum, mild dyspnea, night sweats, myalgias, arthralgias, and a malodorous breath. The admission film is shown in figure lB. Thoracentesis revealed a profusion of Aspergi!lus fumigatus together with Serratia marscescens. Pleural biopsy showed evidence of organizing suppurative senositis consistent with empyema, but no evidence of invasion by aspergillosis. No acid-fast bacilli were found, and blood cultures were negative. Following chest drainage and treatment with antibiotics, including amphotenicin B, the pleural infection improved; he underwent a two-stage thoracoplasty, left pneumonectomy, and decortication. The excised ribs showed no evidence of osteomyelitis. The left lung showed fibrosis and organizing pneumonia, while the pleura showed granulation tissue but no evidence of fungus. Case
AND
130:164-166, January Roentgen Ray Society
1978
171 Ashley Avenue, Charleston,
164
Charleston,
South Carolina
South Carolina
29403.
Address
reprint
requests
29403.
0361 -803X/78/01
00-01
64 $02.00
to
Downloaded from www.ajronline.org by 110.38.221.172 on 11/11/15 from IP address 110.38.221.172. Copyright ARRS. For personal use only; all rights reserved
CASE
Fig. 1 -Case film
12 months
1 . A, Frontal later
showing
chest film showing thickened
pleura
chronic
with
left pneumothorax
shaggy
inner
margin.
165
REPORTS
Note
with partial fluid level
atelectasis in left chest
of left lung and pleural and increased atelectasis
-
Fig. 2.-Case 2. A, Frontal chest film after pneumonectomy showing considerable section through pleura showing superficial nature of aspergillosis infection without fungi , Grocott modification, x 200.
two patients [6]. Our radiologic appearance, bordered by a shaggy thickening
has
not
been
two patients with marked inner margin. a feature
showed a similar pleural thickening However, pleural
in all
reported
cases.
thickening deeper
In treating
B have infusion, required
of left pleura
invasion
the
been but to
of the
disease
used
both
treatment sterilize
:
*.
with shaggy inner margin. B, Magnified thickened pleura. Gomori preparation for
[1],
nystatin
parenterally over
the
thickening. B, Admission of left lung.
pleura.
and
and
several An
amphotericin
by intrapleural
months experimental
is
often oral
166
CASE
preparation (BAY b 5097) has been reported effective and nontoxic [7]. Surgical removal of aspemgiliosis-infected pleura and adjacent pulmonary disease provided an effective cure in 10 patients [1].
REPORTS 3. Young AC, Bennett JE, Aspengillosis. Medicine 4. Barlow D: Aspergillosis sis. Proc R Soc Med 47 5.
Downloaded from www.ajronline.org by 110.38.221.172 on 11/11/15 from IP address 110.38.221.172. Copyright ARRS. For personal use only; all rights reserved
REFERENCES 1 . Herring
M, Pecora D: Pleural aspergillosis: 42 :300-302, 1976 2. Libshitz HI, Atkinson GW, Israel HL: Pleural manifestation of aspergillus supeninfection. genol 120 : 883-886, 1974
a case report.
Am Surg
thickening Am
W,
fumigatus
jako
Piotrowski
A,
Kryszkiewicz
T:
Aspergillus
przyczyna powiklania pooperayjnego (Aspergillus fumigatus as the cause of postoperative complications). Gruzlica 27 : 1069, 1959 6. Krakowka P, Aowinska E, Haiweg H: Infection of the pleura
as a
J Roent-
Sitkowski
Vogel CL, Carbone PP, Devita VT: 49 : 147-1 71 , 1970 complicating pulmonary tuberculo: 877, 1954
7.
byAspergillus fumigatus. Thorax 25 : 245-253, 1970 Tardieu P, Diedonne P, Monod 0, Atchoanena JB: Aspergillomes pleuraux. J Franc Med Chir Thor 18 : 591 , 1964
