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Aspergillus empyema and bronchopleural fistula

The management of Aspergillus empyema is often difficult. Pleural aspergillosis is usually a complication of another manifestation of aspergillosis. The most common scenario is following surgical intervention of an aspergilloma or invasive aspergillosis. Typically this results in a pleurocutaneous fistula.

Cultures usually grow Aspergillus and biopsy of the pleura or wall of the cavity confirm the diagnosis. Drainage of an empyema with creation of a deep pleurocutaneous fistula (e.g. an Eloesser flap (Eloesser, 1969) which can heal slowly (over months) is usually necessary, in addition to antifungal therapy. An Eloesser flap procedure consists of a) creation of a superior skin flap, 6 (e.g. B) partial rib section of 1 or 2 ribs and c) entering the pleural cavity and draining all the empyema and d) suturing the skin flap to the upper margin of the pleural defect. In a case managed in this manner with concurrent itraconazole, cultures of tissue from the cavity became negative by 7 weeks and histology by 13 weeks (Denning et al, 1989).

Occasionally an aspergilloma will erode into the pleural cavity spontaneously, creating a bronchopleural fistula. This should be managed in the same way although typically the patients have very significant pulmonary compromise rendering surgery difficult or impossible. In this situation, a combination of systemic antifungal therapy with instillation of amphotericin B paste into the aspergilloma cavity or pleura (or both) is the optimal therapeutic approach. As pleural aspergillosis tends to be chronic and indolent many months of therapy are usually required in this situation and often one can only stabilise the disease and improve symptoms, without full resolution or cure.

Rare instances of pleural aspergillosis have been described without antecedent factors. In such case, the pleura was thick and a complete decortication cured the patient (Kearon et al, 1987). Surgical management (e.g. excision) is emphasised by this and other reports (Chung et al, 1988) but is not technically possible in all cases.

In those few instances in which pleural aspergillosis complicates invasive pulmonary aspergillosis (Albeda et al, 1982; Talbot et al, 1987;) systemic antifungal therapy, as for pulmonary aspergillosis is appropriate. When the patient's platelet count allows instillation of amphotericin B into the pleural cavity may also be helpful.

David W. Denning FRCP FRCPath FIDSA FMedSci
Professor of Medicine and Medical Mycology
Director, National Aspergillosis Centre
Education and Research Centre
University Hospital of South Manchester (Wythenshawe Hospital)
Southmoor Road
Manchester M23 9LT UK