Objective: description of a monocentric series of 26 patients with chronic pulmonary necrotizing aspergillosis and testing of a recent radiological classification. Methods: retrospective analysis of medical records with special focus on evolution and radiological aspects. Results: six patients had a negative search for Aspergillus, all had a positive serology. Intratissulary rods were seen in only 3 of the 10 patients going through surgery. First line treatments consisted in itraconazole for 15 patients, amphotericin B for 10 and voriconazole for 5. Primary failure rate was 22%. During follow-up (47 months), 61% of the respondors relapsed. There was no relapse among the patients with a normalized serology at the end of the treatment. Only 15 patients were easily classified using Denning's recent sub-classification: 9 chronic cavitary forms, 2 chronic fibrosing forms and 4 sub-acute invasive forms. Ambiguity between the "cavitary" and the "fibrosing" forms was frequent, the role of Aspergillus in generating fibrosis being uncertain. Simplifying Dennings' classification into sub-acute and chronic pulmonary aspergillosis, allowed an easy classification of 88% of our patients :- in the sub-acute form, systemic immunodepression was usual, there was one or no excavation, no fibrosis, the search for Aspergillus was usually positive, tissular invasion was seen, locoregional extension was possible, relapses were unusual, surgery was an interesting radical treatment.- in the chronic form, systemic immunodepression was rare, there were multiple excavations, pleural or pulmonary fibrosis was usual and sometimes extensive, search for Aspergillus was often negative, tissular invasion was not easily seen, there was no locoregional extension, relapses were usual with frequent bilateralisation, surgery was often difficult and followed by frequent relapses.
Conclusion: Dennings' recent radiological classification allows a better understanding of this complex disease. We propose a simplified use of this classification, which should help physicians in managing these patients. These 2 forms of pulmonary aspergillosis should also be carefully separated in studies comparing treatment strategies. A sustained antifungal treatment might be interesting in patients with the chronic form.
Full conference title:
- RICAI 24th (2004)