Case 075: Mulch pneumonitis in CGD patient.
Summary:

A 33 year old known Chronic Granulomatous Disorder (CGD) male presented to A&E in respiratory distress and admitted with severe bibasal pneumonia. He had been laying mulch in his garden. He had not been taking any prophylactic antifungal agents. Oxygen therapy was commenced in conjunction with IV bacterial and fungal treatment with Amphotericin B (Fungizone®). Further consultation and an adverse reaction to the administration of Fungizone® led to a switch to IV Voriconazole 300mg BD. The patient declined a bronchoscopy, responded well to IV voriconazole and was discharged home 2 weeks post admission on maintenance voriconazole.  

Comments:

Diagnosis:
Aspergillus antibodies were detected in the blood but in the absence of a sputum or BAL sample to confirm or refute an aspergillosis infection a possible diagnosis of acute invasive pulmonary aspergillosis was made based on the clinical presentation, the history of laying fresh mulch in the garden and the radiological appearance. [See Holland et al 2007 in “Fulminant Mulch Pneumonitis” Clinical Infectious Diseases 2007; 45:673–81]. Aspergillus fumigatus  antibodies (precipitins) were detectable in serum, but they have not yet been considered useful diagnostic criteria for invasive aspergillosis, especially without a rising titre.

Response to antifungal therapy:
Following treatment with IV voriconazole a marked benefit was noted with a downward trend in the CRP, improvement in symptoms and radiological evidence of resolution of consolidation.

Outcome:
Overall a very good response to voriconazole therapy in the absence of previous prophylactic antifungal treatment with Itraconazole which is recommended for adult CGD patients. The patient remains well at present.

Images

Case Report by Marie Kirwan, CGD Nurse, University Hospital of South Manchester, Manchester UK .