BRIEF REPORTS
Pulmonary Aspergillosis: An Unusual Cytologic Presentation Michael W. Stanley,
M.D.,
Scott Davies, M.D., and Marcia Deike,
Cytologic identi’jication of Aspergillus is usually based on recognition of hyphal elements; conidia are rarely seen. We report a case of autopsy-proven pulmonary AspergillosiJ which was studied antemortem by bronchoalveolar lavage. This mass arose in the clinical setting of chronic necrotizing pulmonary aspergillosis. The specimen contained numerous conidia, some of which exhibited germination. No hyphae were seen. This unusual cytologic expression of clinically signi’jkant fungal disease could be easily overlooked. Distinction of Aspergillus conidra from contaminating pollen is discussed. Diagn Cytopathol 1992;8:585-587. 4 1992 Wilev-I.iss, Inc Key Words: Lung; Cytology; Aspergillus: Mycetoma; Bronchoalveolar lavage
Lung infection with Aspergillus takes several forms. In general, the degree of invasiveness ofthe organism is inversely proportional to the host’s immunocompetence and includes asymptomatic colonization, noninvasive mycetomas and invasive aspergillosis. Immunologic reactions to this organism also cause disease: extrinsic allergic alveolitis and allergic bronchopulmonary Aspergillosis. Less well known is the condition variously designated as “semiinvasive,” chronic granulomatous or chronic necrotizing pulmonary aspergillosis (CNPA). Tissue invasion without vascular involvement defines CNPA and distinguishes this condition from simple mycetoma. However, tissue invasion by fungal hyphae has not been demonstrated in all cases reported to meet the clinical criteria for this diagnosis. Progressive parenchymal disease characterized radiographically by the development of a lung cavity in an area that was previously normal or involved by noncavitary disease is an important part of the clinical identification of this disorder. The cavity may or may not subsequently come to house a Received February 3, 1992. Accepted March 20, 1992. From the Department of Pathology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas; Departments of Medicine, Laboratory Medicine, Hennipin County Medical Center, Minneapolis, Minnesota. Address reprint requests to Dr. Michael W. Stanley, Department of Pathology, Slot-5 17, University of Arkansas for the Medical Sciences, 4301 West Markham, Little Rock, AR 72205. ci 1992
WILEY-LISS, INC
M.S.
mycetoma. Pleural involvement can also be seen. In those cases lacking tissue confirmation of fungal disease, serologic evaluation and sputum culture are important features of the diagnosis. The typical cytologic manifestation of pulmonary aspergillosis is septate, branching hyphae. The clinical relevance of hyphal identification is not always clear, since colonization is very common and may be unrelated to clinical lung disease in the immunocompetent individual. It is more likely to be significant in the immunosuppressed patient, but the diagnosis of aspergillosis continues to be based on a combination of clinical, historical, radiographic, cytologic, and culture data. The conidia of Aspergillus are rarely identified in cytologic material, even though they are commonly present in the environment. We describe the cytologic findings in an immunocompetent patient with autopsy-proven CNPA from whom bronchoalveolar lavage (BAL) fluid contained numerous conidia consistent with those of Aspergillus niger. No hyphae were identified, even retrospectively. This unusual cytologic presentation of significant pulmonary Aspergillosis has not previously been discribed in the cytology literature.
Case Report The patient was a 64-yr-old woman with atherosclerotic coronary vascular disease and chronic obstructive pulmonary disease (COPD). Medications included albuterol by metered dose inhaler, aspirin, and dipyridamole. She had previously received one year of isoniazid for conversion of her tuberculin skin test. She had had coronary artery bypass surgery 4 mo before admission. She was admitted with a 1-mo history of fever and chills. She had a minimal cough and no shortness of breath. The chest roentgenogram showed a large infiltrate with cavitation in the right upper lobe, which was new since a chest roentgenogram 2 months earlier. Secretions were scanty but purulent. Cultures of sputum grew normal flora and Aspergillus niger. Three sputum smears for acid-fast bacteria were negative. Fiberoptic bronchoscopy and BAL of the right upper Diagnostic Cytopuihology, Vol 8, No 6
585
Fig. C-1
FGg. C-3
Fig. C-2
Fig. C-4
Figs. C-1-C-4. Fig. C-1. Four conidia are clustered here. They are yellow-brown and feature numerous surface spikes (Papanicolaou stain, X 788). Fig. C-2. This conidium has a wall similar to that in Fig. C-1. Germination has occured through a fracture (Papanicolaou stain, ~ 7 8 8 ) Fig. . C-3. Another germinating conidium is shown here (Diff-Quik stain, X788). Fig. C-4. Sections show a thick fibroinflammatory wall. This is separated by an artifactual space from a mass of tangled hyphae (H&E, x 312).
PULMONARY ASPERGILLOSIS
lobe were done. Endobronchial anatomy was normal. The lavage fluid had 45% neutrophils, 35% lymphocytes, 4% eosinophils, and 8% macrophages. Cultures of this fluid grew A. niger, and no other pathogens were isolated. Serum antibodies to A. niger were present at a titer of 1:640. While waiting for final culture results, the patient developed acute dyspnea, cough productive of green sputum, extensive bilateral infiltrates, and refractory hypotension. She died of presumed hospital-acquired bacterial pneumonia despite broad-spectrum antimicrobial therapy.
Materials and Methods BAL was performed using standard technique, as previously discribed. Six cytocentrifuge slides were either air-dried or fixed in 95% ethanol for a Diff-Quik or Papanicolaou stain, respectively. Autopsy tissues were formalin-fixed, paraffin-embedded, sectioned at 4 pm, and stained with hematoxylin-eosin.
Results The radiographic progression of this patient’s lung disease, as well as the antemortem microbiologic findings, were summarized in the case report. The BAL fluid showed marked neutrophilia and lymphocytosis, with a corresponding decrease in the number of macrophages. Bronchial cells were also present. Spherical, yellow/ brown, markedly echinulate conidia consistent with those of Aspergillus niger were present singly and in small clusters. These were approximately one-half the diameter of a red blood cell and frequently showed germination from a fractured, but recognizable conidial wall (Figs. C- 1-C-3). Fungal hyphae were not identified, even when the slides were reexamined in the light of the autopsy findings. At autopsy, the lungs showed both bacterial pneumonia and fungal disease. The former was manifest as large areas of acute and organizing consolidation. The latter showed a mycetoma measuring 12 x 7 x 5 cm. The center of this lesion was filled with tangled masses of hyphae. Numerous polarizable crystals morphologically consistent with oxalate were noted, and conidia were numerous. Complete fruiting heads were not identified in the several sections available for histologic study. This mass had a thick fibroinflammatory wall (Fig. C-4). Invasive growth of fungal hyphae was not identified.
Discussion This case was classified as CNPA on the basis of the pattern of disease progression, in the absence of documented invasive fungal growth (see clinical history). The patient’s death was attributable to rapidly progressive bacterial pneumonia. The cavity created by fungal disease housed an aspergil-
loma. These lesions are rarely visualized bronscopically but can be diagnosed by FNA. BAL showed numerous conidia, but hyphae were not identified. The fruiting heads of Aspergillus arise by expansion of a conidiophore from which phialides arise and come to be decorated by chains of conidia. The morphology of the fruiting head and conidia form the basis for speciation of Aspergillus isolates. It is unusual to see conidia in cytologic material; one usually identifies hyphae. This report documents clinically significant pulmonary aspergillosis represented by numerous conidia in a BAL specimen. Awareness of this apparently rare phenomenon may improve cytologic diagnosis of this disorder. Two problems attend the type of diagnosis discribed herein. First, it would be easy to overlook the very small conidia. Their distinctive color and rough surface help make them stand out as the slide is examined at intermediate magnification. They were numerous in the case we have illustrated and would have been difficult to overlook. The second potential problem is that once visualized, the conidia could be mistaken for pollen, which is a common contaminant in cytologic specimens. Granules of pollen are much larger than the conidia we have illustrated, but they may have surface spikes. In Papanicolaou-stained preparations, they are usually pale or eosinophilic, rather than showing endogenous pigmentation. In most instances, only rare pollen granules are present, whereas the conidia in our case were numerous. Whether Aspergillus is identified as hyphae or as conidia, its clinical significance may not be readily apparent, and can certainly not be deduced solely from study of cytologic material. The conclusion that this organism is responsible for clinical lung disease continues to rest on a combination of several observations.
’
637
References 1. Rohatgi PK, Rohatgi NB. Clinical spectrum of pulmonary aspergillosis. South Med J 1984;77:1291-1301. 2. Gefter WB, Weingrad TR, Epstein DM, Ochs RH, Miller WT. “Semi-invasive” pulmonary aspergillosis. Radio1 I98 I; 140:313-321. 3. Binder RE, Faling LJ, Pugatch RD, Mahasaen C, Snider GL. Chronic necrotizing pulmonary aspergillosis: a discrete clinical entity. Medicine (Baltimore) 1982;61:109-124. 4. Stanley MW, Henry-Stanley MJ, Iber C. Bronchoalveolar lavage: cytology and clinical applications. New York: Igaku-Shoin 1991 : 100- 102. 5. Grotte D, Stanley MW, Swanson PE, Henry-Stanley M, Davies S. Reactive type I1 pneumocytes in bronchoalveolar lavage fluid from patients with the adult respiratory syndrome can be mistaken for cells of adenocarcinoma. Diagn Cytopathol 1990;6:317-322. 6. Smith RL, Morelli MJ, Aranda CP: Pulmonary aspergilloma diagnosed by fiberoptic bronchoscopy. Chest 1987;92:948-949. 7. Verea-Hernando H, Martin-Egana M, Dominguez-Juncal L, Fontan-Bueso J. Bronchoscopic aspect of pulmonary aspergilloma. Chest 1989;95:708-709. 8. Stanley MW, Knoedler J, Davies S . Diagnosis of pulmonary aspergilloma by fine needle aspiration. Acta Cytol 1991;35:616-617.
Diagnostic Cytopathology, Vol 8, No 6
587
Pulmonary Aspergillosis: An Unusual Cytologic Presentation Michael W. Stanley,
M.D.,
Scott Davies, M.D., and Marcia Deike,
Cytologic identi’jication of Aspergillus is usually based on recognition of hyphal elements; conidia are rarely seen. We report a case of autopsy-proven pulmonary AspergillosiJ which was studied antemortem by bronchoalveolar lavage. This mass arose in the clinical setting of chronic necrotizing pulmonary aspergillosis. The specimen contained numerous conidia, some of which exhibited germination. No hyphae were seen. This unusual cytologic expression of clinically signi’jkant fungal disease could be easily overlooked. Distinction of Aspergillus conidra from contaminating pollen is discussed. Diagn Cytopathol 1992;8:585-587. 4 1992 Wilev-I.iss, Inc Key Words: Lung; Cytology; Aspergillus: Mycetoma; Bronchoalveolar lavage
Lung infection with Aspergillus takes several forms. In general, the degree of invasiveness ofthe organism is inversely proportional to the host’s immunocompetence and includes asymptomatic colonization, noninvasive mycetomas and invasive aspergillosis. Immunologic reactions to this organism also cause disease: extrinsic allergic alveolitis and allergic bronchopulmonary Aspergillosis. Less well known is the condition variously designated as “semiinvasive,” chronic granulomatous or chronic necrotizing pulmonary aspergillosis (CNPA). Tissue invasion without vascular involvement defines CNPA and distinguishes this condition from simple mycetoma. However, tissue invasion by fungal hyphae has not been demonstrated in all cases reported to meet the clinical criteria for this diagnosis. Progressive parenchymal disease characterized radiographically by the development of a lung cavity in an area that was previously normal or involved by noncavitary disease is an important part of the clinical identification of this disorder. The cavity may or may not subsequently come to house a Received February 3, 1992. Accepted March 20, 1992. From the Department of Pathology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas; Departments of Medicine, Laboratory Medicine, Hennipin County Medical Center, Minneapolis, Minnesota. Address reprint requests to Dr. Michael W. Stanley, Department of Pathology, Slot-5 17, University of Arkansas for the Medical Sciences, 4301 West Markham, Little Rock, AR 72205. ci 1992
WILEY-LISS, INC
M.S.
mycetoma. Pleural involvement can also be seen. In those cases lacking tissue confirmation of fungal disease, serologic evaluation and sputum culture are important features of the diagnosis. The typical cytologic manifestation of pulmonary aspergillosis is septate, branching hyphae. The clinical relevance of hyphal identification is not always clear, since colonization is very common and may be unrelated to clinical lung disease in the immunocompetent individual. It is more likely to be significant in the immunosuppressed patient, but the diagnosis of aspergillosis continues to be based on a combination of clinical, historical, radiographic, cytologic, and culture data. The conidia of Aspergillus are rarely identified in cytologic material, even though they are commonly present in the environment. We describe the cytologic findings in an immunocompetent patient with autopsy-proven CNPA from whom bronchoalveolar lavage (BAL) fluid contained numerous conidia consistent with those of Aspergillus niger. No hyphae were identified, even retrospectively. This unusual cytologic presentation of significant pulmonary Aspergillosis has not previously been discribed in the cytology literature.
Case Report The patient was a 64-yr-old woman with atherosclerotic coronary vascular disease and chronic obstructive pulmonary disease (COPD). Medications included albuterol by metered dose inhaler, aspirin, and dipyridamole. She had previously received one year of isoniazid for conversion of her tuberculin skin test. She had had coronary artery bypass surgery 4 mo before admission. She was admitted with a 1-mo history of fever and chills. She had a minimal cough and no shortness of breath. The chest roentgenogram showed a large infiltrate with cavitation in the right upper lobe, which was new since a chest roentgenogram 2 months earlier. Secretions were scanty but purulent. Cultures of sputum grew normal flora and Aspergillus niger. Three sputum smears for acid-fast bacteria were negative. Fiberoptic bronchoscopy and BAL of the right upper Diagnostic Cytopuihology, Vol 8, No 6
585
Fig. C-1
FGg. C-3
Fig. C-2
Fig. C-4
Figs. C-1-C-4. Fig. C-1. Four conidia are clustered here. They are yellow-brown and feature numerous surface spikes (Papanicolaou stain, X 788). Fig. C-2. This conidium has a wall similar to that in Fig. C-1. Germination has occured through a fracture (Papanicolaou stain, ~ 7 8 8 ) Fig. . C-3. Another germinating conidium is shown here (Diff-Quik stain, X788). Fig. C-4. Sections show a thick fibroinflammatory wall. This is separated by an artifactual space from a mass of tangled hyphae (H&E, x 312).
PULMONARY ASPERGILLOSIS
lobe were done. Endobronchial anatomy was normal. The lavage fluid had 45% neutrophils, 35% lymphocytes, 4% eosinophils, and 8% macrophages. Cultures of this fluid grew A. niger, and no other pathogens were isolated. Serum antibodies to A. niger were present at a titer of 1:640. While waiting for final culture results, the patient developed acute dyspnea, cough productive of green sputum, extensive bilateral infiltrates, and refractory hypotension. She died of presumed hospital-acquired bacterial pneumonia despite broad-spectrum antimicrobial therapy.
Materials and Methods BAL was performed using standard technique, as previously discribed. Six cytocentrifuge slides were either air-dried or fixed in 95% ethanol for a Diff-Quik or Papanicolaou stain, respectively. Autopsy tissues were formalin-fixed, paraffin-embedded, sectioned at 4 pm, and stained with hematoxylin-eosin.
Results The radiographic progression of this patient’s lung disease, as well as the antemortem microbiologic findings, were summarized in the case report. The BAL fluid showed marked neutrophilia and lymphocytosis, with a corresponding decrease in the number of macrophages. Bronchial cells were also present. Spherical, yellow/ brown, markedly echinulate conidia consistent with those of Aspergillus niger were present singly and in small clusters. These were approximately one-half the diameter of a red blood cell and frequently showed germination from a fractured, but recognizable conidial wall (Figs. C- 1-C-3). Fungal hyphae were not identified, even when the slides were reexamined in the light of the autopsy findings. At autopsy, the lungs showed both bacterial pneumonia and fungal disease. The former was manifest as large areas of acute and organizing consolidation. The latter showed a mycetoma measuring 12 x 7 x 5 cm. The center of this lesion was filled with tangled masses of hyphae. Numerous polarizable crystals morphologically consistent with oxalate were noted, and conidia were numerous. Complete fruiting heads were not identified in the several sections available for histologic study. This mass had a thick fibroinflammatory wall (Fig. C-4). Invasive growth of fungal hyphae was not identified.
Discussion This case was classified as CNPA on the basis of the pattern of disease progression, in the absence of documented invasive fungal growth (see clinical history). The patient’s death was attributable to rapidly progressive bacterial pneumonia. The cavity created by fungal disease housed an aspergil-
loma. These lesions are rarely visualized bronscopically but can be diagnosed by FNA. BAL showed numerous conidia, but hyphae were not identified. The fruiting heads of Aspergillus arise by expansion of a conidiophore from which phialides arise and come to be decorated by chains of conidia. The morphology of the fruiting head and conidia form the basis for speciation of Aspergillus isolates. It is unusual to see conidia in cytologic material; one usually identifies hyphae. This report documents clinically significant pulmonary aspergillosis represented by numerous conidia in a BAL specimen. Awareness of this apparently rare phenomenon may improve cytologic diagnosis of this disorder. Two problems attend the type of diagnosis discribed herein. First, it would be easy to overlook the very small conidia. Their distinctive color and rough surface help make them stand out as the slide is examined at intermediate magnification. They were numerous in the case we have illustrated and would have been difficult to overlook. The second potential problem is that once visualized, the conidia could be mistaken for pollen, which is a common contaminant in cytologic specimens. Granules of pollen are much larger than the conidia we have illustrated, but they may have surface spikes. In Papanicolaou-stained preparations, they are usually pale or eosinophilic, rather than showing endogenous pigmentation. In most instances, only rare pollen granules are present, whereas the conidia in our case were numerous. Whether Aspergillus is identified as hyphae or as conidia, its clinical significance may not be readily apparent, and can certainly not be deduced solely from study of cytologic material. The conclusion that this organism is responsible for clinical lung disease continues to rest on a combination of several observations.
’
637
References 1. Rohatgi PK, Rohatgi NB. Clinical spectrum of pulmonary aspergillosis. South Med J 1984;77:1291-1301. 2. Gefter WB, Weingrad TR, Epstein DM, Ochs RH, Miller WT. “Semi-invasive” pulmonary aspergillosis. Radio1 I98 I; 140:313-321. 3. Binder RE, Faling LJ, Pugatch RD, Mahasaen C, Snider GL. Chronic necrotizing pulmonary aspergillosis: a discrete clinical entity. Medicine (Baltimore) 1982;61:109-124. 4. Stanley MW, Henry-Stanley MJ, Iber C. Bronchoalveolar lavage: cytology and clinical applications. New York: Igaku-Shoin 1991 : 100- 102. 5. Grotte D, Stanley MW, Swanson PE, Henry-Stanley M, Davies S. Reactive type I1 pneumocytes in bronchoalveolar lavage fluid from patients with the adult respiratory syndrome can be mistaken for cells of adenocarcinoma. Diagn Cytopathol 1990;6:317-322. 6. Smith RL, Morelli MJ, Aranda CP: Pulmonary aspergilloma diagnosed by fiberoptic bronchoscopy. Chest 1987;92:948-949. 7. Verea-Hernando H, Martin-Egana M, Dominguez-Juncal L, Fontan-Bueso J. Bronchoscopic aspect of pulmonary aspergilloma. Chest 1989;95:708-709. 8. Stanley MW, Knoedler J, Davies S . Diagnosis of pulmonary aspergilloma by fine needle aspiration. Acta Cytol 1991;35:616-617.
Diagnostic Cytopathology, Vol 8, No 6
587
