Journal of the Royal Society of Medicine Volume 85 December 1992 The pericardial space should not be irrigated with betadine'0. Constriction may be less common in pneumococcal than in tuberculous effusions where fibrosis is marked. The main advantage of catheter drainage is avoiding pericardial surgery in ill patients, particularly those with m3ycarditis or biventricular dysfunction'. In a n, in patients with limited recurrence of their effusion, an indwellingtcatheter may be removed at an early stage. More reports of.this promising, relatively non-invasive, inexpesive approach to the treatment of pericardial effusion are required. References 1 Kauffman CA, Watanakunakorn C, Phair JP. Purulent pneumococcal pericarditis, a continuing psvblem in the antibiotic era. Am J Med 1973;54:743-50 2 Boyle JD, Pearce ML, Guze LB. Purulent pericarditis: review of literature and report of eleven cases. Medicine (Baltimore) 1961;4:119-39 3 Klacsman PG, Bulkley BH, Hutchins GM. The changed spectrum of purulent pericarditis, an 86 year autopsy experience in 200 patients. Am J Med 1977;63:666-73

Progressive chronic pulmonary aspergillosis: a diagnostic and therapeutic challenge

M E Ellis MD FRCP1 M Dossing MD' A Al-Hokail MBBS' S H Qadri PhD2 B Hainau MD2 J Burnie MD3 Departments of 'Medicine and 2Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Kingdom of Saudi Arabia and 3University Department of Microbiology, University of Manchester Medical School Manchester Keywords: Aspergillus; antigen

We describe an unusual case ofAspergillus flavus associated chronic invasive pulmonary aspergillosis in a normal host and highlight the difficult problems of diagnosis and management. Case report An 18-year Saudi woman presented with 4 months of cough, haemoptysis, weight loss and dyspnoea. She deterioratedcon antituberculosis therapy. Examnation showed a grossly well person. There were diminished breath sounds at the left lung base and right apex. A grade 4/6 pan systolic murmur was audible in the interscapular region. Radiological investigations showed large masses in the right upper lobe, right perihilar, left lower lobe and left pulmonary window which invaded the main bronchi and pulmonary arteries (Figure 1). Pulmonary arteriography confirmed moderate constriction of the right main pulmonary artery and left main pulmonary artery branches with the pulmonary arterial pressure elevated to 50/33 mmHg. Routine haematological and biochemical profiles were normal. FEV,IFVC was 0.75/0.89 (predicted 2.75/3.05). The Pao2 on room air/40% F102 was 10.2 kPa/16 kPa. Oxygen saturation was 92%, and the tuberculin test (10 TU)' negative. The total serum IgE was Correspondence to: Dr M E Ellis, Department of Medicine (MBC 46), King Faisal Specialist Hospital and Research Centre, PO Box 3354, Riyadh 11211, Kingdom of Saudi Arabia

4 Rubin RH, Moellering RC. Clinical, microbiologic and theraait Am JMed 1975;59668-78 peutic aspects of puext 5 Markiewicz W, Borovik R, Ecker S. Cardiae tamponade il medical patients: treatment and progno i the echocardiographic era. Am Heart J 1986;11*:1138-426 Knaus WA, Draper EA, Wagner DP, Zimn JE. APACIIS g Crit Care Med H: a severity of disease cla tio

1985;13:818-28

7 Tan JS, Holmes JC, Fowler NO, Maatsas GT, Phair JP. Antibiotic levels in pericardigl flid. J CUn Invest 1974;53:40-5 8 Morgan RJ, Stephenson LW, Woolf PK, Edie RN, Edmunds LH. Surgical treatment of pWu et peidits in children. J Thorac

Cardiouvasc Surg 1983,;85:27-31t 9 Cameron EWJ. Surgicalmanagement of staphylococcal pencarditis. Thorax 1975;MP6nr81 10 Miller JI, Mansour KA, HatcRir CR. Pericardiectomy: current indications, concepts, and results in a University centre. Ann Thorac Surg 1982;34:40-5

(Accepted 11 September 1991)

elevated to 5520 g/l (n2 a=1-1200). The serum angio, urinary Qium were tensin converting enzymer in urine. normal. Free hydroxyproliR was Sputum was negative for acid-fast bcillus(AFB). Fungal antigen was not det dinseru&h. ere-ws a, significant rise in respiratory7ya 1 in 16 to 1 in 512 which cineiNduh Utbsolute erieux CM, lymphocyte count from 3.8 tol)7 10. Th* inditated anergy. skin test to seven recl a , lymphocyte blastognesis Lymphocyte subsets w and polymorph chemotaxi were normal. Fibreoptic bronchoscopy shoed an revel 1+ with white raised fleck&. e eb leathery lymph nodes whch ouhil1oft sed circumscript dense fibrtic e wi& oesxal multinucleate giant cells..withot netrosis. M y gi were nt (Figure 2). l 2ymphoma was present but AFBs were gbi rmed t not demonstrated. A these features. lbVe Ied Aspergi1lus flavus Culture of the lyzn (>-2 mg/ml) and sensitive to with resistance to rifi amphotericin B (< 2 mg/ml). Serum fungicidal titres were 1/16 (immediate post infusion of amphotericin B), 1/4 (6 h) and > 1/1 (12 h). Antigen was prepared from the patient's Aspergillus isolate'. On gel electrophoresis with anti-human IgM and IgG, a band was identified approximating to a 42 KD size antigen. Specific IgE was not detected. The patient was commenced on intravenous amphotericin B, 0.5 mg/kg daily and rifampicin 450 mg daily. A small dose of prednisolone (20 mg reducing to 10 mg daily) for the intense inflammatory reaction was added together with isoniazid chemoprophylaxis isoniazid 300 mg daily. She deteriorated clinically and radiologically over the next 4 months becoming dyspnoeic on ordinary household chores. In order to exclude a missed malignancy, an open lung biopsy was performed but she died from uncontrolled bleeding accelerated by pulmonary hypertension (75/40 mmHg) in the postoperative period. Di8cussion

Chronic necrotizing pulmonary aspergillosis in association with Aspergillus flavus rather than fumugatus is unusual2. It can mimick TB and sarcoid but these were-excluded. The usual host defense associated defects were also excluded neutrophil macrophage dysfunction2, severe neutropaenia4, exogenous high dose steroids6, chronic obstructive airways disease6, alcoholism7, though an unproven neutrophil defect may still have been present8. However, the pre-terminal

763

764

Journal of the Royal Society of Medicine Volume 85 December 1992

4

4

Figure 2. Lymph node biopsy staine with Gomori's silver methenamine showing dense fibrotic avascular area on the right with numerous fungi On the left the intact lymphatic tissue shows only reactive changes with no evidence of lymphoma

nature of the disease process, noted on histology. Alternative therapies and approaches could have included inhaled amphotericin B11 though unlikely to reach hypoventilated areas, combined antifungal therapy - we chose amphotericin B and rifampicin' - and alternative antifungal preparations such as itraconazole13 and liposomal amphotericin B. Chronic invasive pulmonary aspergillosis is a severe disease even in normal hosts and sets. a challenge for early specific diagnosis and effective chemotherapy. Acknowledgments: We are grateful to Dr Bruce Dunn, Consultant Cardiologist for performing and interpreting the pulmonary angiography.

Figure 1. Top, Infiltrate with atelectasis in the right upper lobe Infiltrate in the right perihilar region with presence of a mass legion. Soft tissue both prominent in the pulmonary region on the left and infiltrates in the left lower lobe associated with possible stenosie of the left lower lobe bronchus. Bottom,4 MRI! of chest showing exten-sive tumour involving apex of the right lung right hilum, subcranial region, aortic pulmonary region, left hilum and anterior mediastinum. The left main stem bronchus is compressed by tumour and so0 is the left pulmonary artery

lymphopaenia associated with RSV infection may have been contributory - deterioration of invasive aspergillosis in association with viral infections notably, influenza has been previously noted9. Our patient was able to produce specific IgM and IgG towards a 42 KD antigen of Aspergillus flavus. It has been suggested that the presence of antibody to a 40 KD antigen of Aspergillus fumigatus may have diagnostic/prognostic value10. If this test had been available earlier in our patient then earlier, treatment may have been beneficial. Patients with invasive aspergillosis and specific antigen antibodies may have a good prognosis but this was not so in our patient. The cause of our patient's demise may have been exceptional fungal virulence or subacute therapeutic drug tissue concentrations despite adquate serum fungicidal levels. The latter is distinctly possible in the light of the highly avascular

References 1 Burnie JP, Matthews RC, Clark I, Milne, LJR. Immunoblot fingerprinting Aspergillus fumigatus. J Immunol Methods 1989;118:179-86 2 Binder RE, Faling J, Pugatch RD, Mahasaen C, Snider SL. Chronic necrotizing pulmonary aspergillosis: a discrete clinical entity. Medicine 1982;61:109-24 3 Kelly JK, Pinto AR, Whitelaw WA, Rorstad OP, Brown TJ, Matheson DS. Fatal Aspergillus pneumonia in chronic granulomatous disease. Am J Clin Pathol 1986;86:235-40 4 Schaffner A, Douglas H, Braude A. Selective protection against conidia by mononuclear and against mycelia by polymorphonuclear phagocytes in resistance to Aspergillus. Observations on these two lines of defense in vivo and in vitro with human and mouse phagocytes. J Clin Invest 1982;69:617-31 5 Wiggins J, Clark TJH, Corrin B. Chronic necrotsing pneumonia caused by Aspergillus niger. Thorax 1989;44:440-1 6 George PJM, Boffa PBJ, Naylor CPE, Higenbottam TW. Necrotising pulmonary aspergillosis complicating the management of patients with obstructive airways disease. Thorax 1983;88:478-80 7 Blum J, Reed JC, Pizzo SV, Thompson MW. Miliary aspergillosis associated with alcoholism. Am J Radiol 1978;131:707 8 Cook DJ, Achong MR, King DEL. Dieminated aspergillosis in an apparently healthy patient.-Am J-Med 1990;88:74-6 9 Fischer JJ, Walker DH. Invasive pulmonary aspergillosis associated with influenza. JAMA 1979X,241:1493-4 10 Matthews R, Burnie JP, Fox A, Tabaqchali S. Immunoblot analysis of serological responses invasive aspergillosis. J Clin Pathol 1985;38:1300-3 11 Rodenhuis S, Beaumont F, Kauffman HF, Sluiter HJ. Invasive pulmonary aspergillosis in a non-immunosuppressed patient: succesdsl management with systemic amphotericin and flucytosine and inhaled amphatericin. Thorax 1984;39'78-9 12 Arroyo J, Medoff G, Kobayashi GS. Therapy of murine aspergillosis with amphotericin Bin combinaton with infection or 6 fluoroacytosine antimucous agents chemo treatment. Antimicrob Agents Chemother 1977;11:21-5 13 DuPont B, Trouhet E. The treatment of aspergillosis with azole derivatives. In: Vanden Bossche HB, Mackenzie DWR, Cauwengerg HG, eds. Aspergillus and aspergillosis. New York: Plenum Press, 1988:243-51

(Accepted 12 September 1991)

Progressive chronic pulmonary aspergillosis: a diagnostic and therapeutic challenge.

Journal of the Royal Society of Medicine Volume 85 December 1992 The pericardial space should not be irrigated with betadine'0. Constriction may be le...
900KB Sizes 0 Downloads 0 Views