Chronic necrotizing pulmonary aspergillosis: Clinical presentation, diagnosis and treatment

M.Navarro, Ch. Domingo, M. Gallego, R. Comet, A. Ferrer, Ma.D. Maliscal1, A.Marin.


Chronic necrotizing pulmonary aspergillosis (CNPA) is an infrequent type of aspergillosis, which usually affects partially immunosuppressed patients, whose clinical course is slow and whose response to treatment is much more satisfactory than the invasive aspergillosis.Purpose: Clinical description, diagnostic procedures and treatment of three patients with CNPA.Population:3 pts. (2 men); mean age 60 ys (age range 48-81 ys); 1 chronic asthma; 2 chronic bronchitis; 1 pulmonary tuberculosis. Clinical presentation: fever, productive cough, toxic syndrome which had last several months and lung infiltrates in the Chest X-ray (XR).Methods: 1) Blood analysis (BA); 2) XR & computed tomography scan (CTcan);3)Diagnostic procedures: we performed cultures to investigate the presence of anaerobic bacteria, mycobacteria, fungus and Nocardia of the following smears: sputum, bronchoaspirate, broncho-alveolar lavage, quantitative protected specimen brush and aspirative pulmonary puncture. 4) Empiric treatment for anaerobic germens with amoxy-clavulanic was undertaken.Results: 1) BA: ESR 125 ± 4.2 mm/h, 18.3 + 6.6 x 109 Leukocytes/1; Hb 9.3 + 0.91 g/dl. 2) XR and CTScan: cavitated unilateral infiltrates in 2 cases and bilateral in the third one, 3) Absence of growth of bacteria and mycobacteria in the pulmonary secretions. 4) Positive culture of the different smears for Aspergillus fumigatus. 5) No response to anaerobic treatment. 6) Clinical, biological and radiological improvement (ESR 67 + 25.4 mmlh; Hb 10.5 - 0.7 g/dl; Leukocytes 18.3 + 6.64 x 109/1) in two cases after treatment with Amphoterin B and Itraconazole. One patient died because of a pneumococcal pneumonia.Conclusions: 1) We should suspect a CNPA in those partially imrnunosupressed patients, with respiratory symptoms which last during several weeks or months, in whom an infection due to anaeobic germens and mycobacterium has been ruled out, when positive cultures of respiratory smears for Aspergillus have been obtained. 2) Treatment with Amphotericin B followed by oral ltraconazole was effective in two cases. 3) In this clinical and radiological setting, after ruling out other infectious diseases, the diagnosis of CNPA must be accepted without performing a lung biopsy.

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7th European Respiratory Society Annual Conference
    • ERS 17th (2007)