Cystic fibrosis (CF) is an inherited multisystem disorder characterized mainly by chronic obstructive lung disease. The lung destruction is caused by a cycle of airway obstruction, infection and chronic colonization with specific bacterial pathogens, especially Pseudomonas aeruginosa and Staphylococcus aureus. The development of large pulmonary abscess cavities is exceedingly uncommon. Here, we present two rare clinical cases of CF patients who developed lung abscess due to A. fumigatus infection which might be characterized as forms of cavitary pulmonary aspergillosis.
A 13-year-old male CF patient presented with sore throat and high fever not responding to antibiotic treatment for about 15 days. Clinical examination revealed torticollis and painful swelling of the thyroid gland, while lung auscultation was normal. Laboratory parameters were WBC=17,230 /mm3, CRP=141 mg/l, IgE=15 u/ml. Thyroid ultra sound (US) demonstrated swelling of the isthmus and the left lobe. Patient received meropenem, teicoplanin, amikacin and corticosteroids for the thyroid inflammation and he became afebrile after two days. On day 12, patient presented with fever and the new thyroid US revealed thyroid abscess 4.6x3.9x2.4 cm, while the CXR demonstrated consolidation on the right upper lobe. Drainage of the thyroid abscess was performed and all pus cultures were negative for fungi and non tuberculous mycobacteria. Treatment changed to linezolid, piperacillin/tazobactam and patient became afebrile after two days. On day 18, patient presented again with fever and symptoms from the respiratory system. New CXR revealed a lung abscess with an air-fluid level located in the right upper lobe, while the chest CT revealed two consolidations on the right lung, bronchiectasis and mediastinal lymph nodes. Cultures from pneumocentesis grew A. fumigatus, PCR for A. fumigatus was positive. Serum A. fumigatus antibodies were not detected. Cultures from sputum samples grew Pseudomonas aeruginosa, Candida albicans, A. fumigatus, Serratia, Acinetobacter and Enterobacter cloacae. Meropenem and voriconazole were added to the initial therapy leading to symptoms’ remission and significant improvement in CXR and CT scan.
The second clinical case was a 17-year-old male CF patient who developed fever, cough for 16 days and, finally, pain on the right hemithorax. Patient had been free of P. aeruginosa colonization for the last 12 months. Clinical examination was normal and laboratory parameters were WBC=26,640 /mm3, CRP=82 mg/l, specific IgE for A. fumigatus=0.11u/μl. Imaging tests (CXR, CT) demonstrated a lung abscess in the right lobe with an air-fluid level, peripheral bronchiectasis and pleural infusion. Bronchoscopy was performed and cultures from bronchoalveolar lavage grew Stenotrophomonas maltophilia, Candida parapsilosis and A. fumigatus. PCR for A. fumigatus was positive, while PCR for Mycobacterium tuberculosis was negative. Patient’s initial treatment was changed to cefepime, teicoplanin and voriconazole and his clinical condition, as well as, imaging tests were improved.
Clinical manifestations of A. fumigatus in CF are under intensive research. Although lung abscess as a form of cavitary pulmonary aspergillosis is rarely observed in CF, close monitoring and differential diagnosis for fungal disease should be consideredin CF patients who present symptoms of infection. The timely initiation of anti-fungal and anti-bacterial treatment contributed to our patients’ good response.
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- AAA 7th (2016)