IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES Pulmonary Arterial Mycotic Pseudoaneurysms in a Patient with Invasive Pulmonary Aspergillosis Successful Occlusion by Coils Morgane Didier1, Pierre Guedin2, Fabrice Staub3, Emilie Catherinot1, Elisabeth Rivaud1, Antoine Scherrer3, Colas Tcherakian1, and Louis-Jean Couderc1,4 1 Respiratory Diseases Department, 2Department of Diagnostic and Therapeutic Neuroradiology, and 3Department of Radiology, Hopital ˆ Foch, Suresnes, France; and 4University of Versailles, Saint-Quentin-en-Yvelines, France
A 77-year-old man was admitted for hemoptysis related to invasive pulmonary aspergillosis after chemotherapy for acute myeloid leukemia. Thoracic computed tomography scan disclosed bilateral pulmonary arterial mycotic pseudoaneurysms. He was previously treated with antifungal therapies for 28 days, including 8 days with a combination of voriconazole and caspofungin. The left aneurysm was treated first because of its large size (15 mm) by embolization with intrasaccular Cook coils (Bjaeverskov, Denmark), then the left smaller and the right one were treated similarly, 3 and 4 days later, respectively. Hemoptysis ceased for good after the second coil insertion. No recurrence occurred with further antifungal therapy. The patient died of a leukemia relapse 4 months later. Pulmonary arterial aneurysms may be causative of fatal hemoptysis by rupture of the wall of the feeding vessel (1–3). Endovascular occlusion by intrasaccular coils is effective and minimally invasive (4, 5) and should be now considered as the first-line treatment. n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Visrutaratna P, Charoenkwan P, Saeteng S. Mycotic aneurysm of the left subclavian artery: CT findings. Singapore Med J 2006;47: 77–79. 2. Caillot D, Mannone L, Cuisenier B, Couaillier JF. Role of early diagnosis and aggressive surgery in the management of invasive pulmonary aspergillosis in neutropenic patients. Clin Microbiol Infect 2001;7: 54–61.
3. Yeghen T, Kibbler CC, Prentice HG, Berger LA, Wallesby RK, McWhinney PH, Lampe FC, Gillespie S. Management of invasive pulmonary aspergillosis in hematology patients: a review of 87 consecutive cases at a single institution. Clin Infect Dis 2000;31:859–868. 4. Ghaye B, Trotteur G, Dondelinger RF. Multiple pulmonary artery pseudoaneurysms: intrasaccular embolization. Eur Radiol 1997;7:176–179. 5. Remy J, Lemaitre L, Lafitte JJ, Vilain MO, Saint Michel J, Steenhouwer F. Massive hemoptysis of pulmonary arterial origin: diagnosis and treatment. AJR Am J Roentgenol 1984;143:963–969.
Author Contributions: M.D. contributed to writing and revising the manuscript critically for important intellectual content, literature search, and approval of the final manuscript, and served as principal author. P.G., F.S., E.C., E.R., A.S., and C.T. contributed to writing and revising the manuscript and approval of the final manuscript. L.-J.C. contributed to writing and revising the manuscript and approval of the final manuscript and designed the study. Am J Respir Crit Care Med Vol 190, Iss 1, pp 112–113, Jul 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201310-1780IM Internet address: www.atsjournals.org
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Figure 1. (A) Preembolization multidetector computed tomography postcontrast maximal intensity projection coronal chest image (soft tissue windows) demonstrating three mycotic aneurysms (arrows) (the largest is 15 mm in diameter) with respective pulmonary arterial feeding vessels: two branches of the apical segmental left upper lobe and one apical-dorsal segmental right upper lobe. (B) Preembolization digital substraction pulmonary angiography showing the major pseudoaneurysm of the left upper lobe pulmonary arterial branch. (C) Postembolization angiography showing effective occlusion by intrasaccular Cook detach 18 (Bjaeverskov, Denmark) (50 inches long) coils.
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A 77-year-old man was admitted for hemoptysis related to invasive pulmonary aspergillosis after chemotherapy for acute myeloid leukemia. Thoracic computed tomography scan disclosed bilateral pulmonary arterial mycotic pseudoaneurysms. He was previously treated with antifungal therapies for 28 days, including 8 days with a combination of voriconazole and caspofungin. The left aneurysm was treated first because of its large size (15 mm) by embolization with intrasaccular Cook coils (Bjaeverskov, Denmark), then the left smaller and the right one were treated similarly, 3 and 4 days later, respectively. Hemoptysis ceased for good after the second coil insertion. No recurrence occurred with further antifungal therapy. The patient died of a leukemia relapse 4 months later. Pulmonary arterial aneurysms may be causative of fatal hemoptysis by rupture of the wall of the feeding vessel (1–3). Endovascular occlusion by intrasaccular coils is effective and minimally invasive (4, 5) and should be now considered as the first-line treatment. n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Visrutaratna P, Charoenkwan P, Saeteng S. Mycotic aneurysm of the left subclavian artery: CT findings. Singapore Med J 2006;47: 77–79. 2. Caillot D, Mannone L, Cuisenier B, Couaillier JF. Role of early diagnosis and aggressive surgery in the management of invasive pulmonary aspergillosis in neutropenic patients. Clin Microbiol Infect 2001;7: 54–61.
3. Yeghen T, Kibbler CC, Prentice HG, Berger LA, Wallesby RK, McWhinney PH, Lampe FC, Gillespie S. Management of invasive pulmonary aspergillosis in hematology patients: a review of 87 consecutive cases at a single institution. Clin Infect Dis 2000;31:859–868. 4. Ghaye B, Trotteur G, Dondelinger RF. Multiple pulmonary artery pseudoaneurysms: intrasaccular embolization. Eur Radiol 1997;7:176–179. 5. Remy J, Lemaitre L, Lafitte JJ, Vilain MO, Saint Michel J, Steenhouwer F. Massive hemoptysis of pulmonary arterial origin: diagnosis and treatment. AJR Am J Roentgenol 1984;143:963–969.
Author Contributions: M.D. contributed to writing and revising the manuscript critically for important intellectual content, literature search, and approval of the final manuscript, and served as principal author. P.G., F.S., E.C., E.R., A.S., and C.T. contributed to writing and revising the manuscript and approval of the final manuscript. L.-J.C. contributed to writing and revising the manuscript and approval of the final manuscript and designed the study. Am J Respir Crit Care Med Vol 190, Iss 1, pp 112–113, Jul 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201310-1780IM Internet address: www.atsjournals.org
112
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 1 | July 1 2014
IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES
Figure 1. (A) Preembolization multidetector computed tomography postcontrast maximal intensity projection coronal chest image (soft tissue windows) demonstrating three mycotic aneurysms (arrows) (the largest is 15 mm in diameter) with respective pulmonary arterial feeding vessels: two branches of the apical segmental left upper lobe and one apical-dorsal segmental right upper lobe. (B) Preembolization digital substraction pulmonary angiography showing the major pseudoaneurysm of the left upper lobe pulmonary arterial branch. (C) Postembolization angiography showing effective occlusion by intrasaccular Cook detach 18 (Bjaeverskov, Denmark) (50 inches long) coils.
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