Date: 26 November 2013
Aspergillus terreus Thom. Conidial head of Aspergillus terreus. Conidial heads are compact, columnar and biseriate. Conidiophores are hyaline to slightly yellow and smooth walled.
Copyright:
With thanks to G Kaminski. D Ellis and R Hermanis Mycology Unit, Women’s & Children’s Hospital , Adelaide, South Australia 5006
Notes:
Colonies on CYA 40-50 mm diam, plane, low and velutinous, usually quite dense; mycelium white; conidial production heavy, brown (Dark Blonde to Camel, 5-6D4); reverse pale to dull brown or yellow brown. Colonies on MEA 40-60 mm diam, similar to those on CYA or less dense. Colonies on G25N 18-22 mm diam, plane or irregularly wrinkled, low and sparse; conidial production light, pale brown; brown soluble pigment sometimes produced; reverse brown. No growth at 5°C. Colonies at 37°C growing very rapidly, 50 mm or more diam, of similar appearance to those on CYA at 25°C.Conidiophores borne from surface hyphae, stipes 100-250 μm long, smooth walled; vesicles 15-20 μm diam, fertile over the upper hemisphere, with densely packed, short, narrow metulae and phialides, both 5-8 μm long; conidia spherical, very small, 1.8-2.5 μm diam, smooth walled, at maturity borne in long, well defined columns.Distinctive featuresVelutinous colonies formed at both 25°C and 37°C, uniformly brown, with no other colouration, and minute conidia borne in long columns make Aspergillus terreus a distinctive species.
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A. Necrotic mass prolapsing in and out of the distal right intermediate bronchus obscuring both the basal stem and basal division
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History : A 20 yr old female with cystic fibrosis complicated by CF-related Diabetes mellitus (diagnosed at age 12 years) & ABPA (diagnosed at
15 years ). She was fairly stable until last 9 months, when she started to experience frequent pulmonary exacerbations, which have prompted intensive therapies.
Her serum IgE at the time of diagnosis was 5060 IU/L, skin prick test for aspergillus was positive, and serum was positive for precipitating antibodies to Aspergillus. She was treated with oral prednisone (1 mg/kg/day) for first two weeks followed by prednisone at 0.5 mg/kg every other day for at least 6 months with some clinical and serologic improvement. Over the following 5 years, she presented with a pattern of repeated episodic exacerbations with wheezing and crackles, increases in IgE and need to increase prednisone dosage. In an attempt to control her frequent ABPA relapses, itraconazole was added at 200mg twice a day, with some clinical & serologic improvement.
2-3 weeks prior to the scans and X rays, she developed severe protracted coughing spells associated with minor hemoptysis, low grade intermittent fever, and weight loss. Her FEV1 declined in a 3 months period from 56% to 33%.
A chest-x ray (Fig 3) did not reveal any new changes when compared to the one obtained almost a year before. A CT scan of the chest Figs 1 and 2- lateral view), however shows an ovoid soft tissue density within an ectatic bronchi in the anterior basal segment of the LLL, felt to be an aspergilloma.She was started on oral voriconazole (3 months after the above scans and X-rays) which is better absorbed in CF patients than itraconazole, at 200mg twice a day. Her prednisone was gradually reduced to 5 mgs/day and her FEV1 increased to 46% of predicted (03/31/10), her IgE level was 1167 kU/L (previously in January 2009, her IgE level was 3053 kU/L)and her weight has plateaued.
Since she was not fit enough for surgery at that time, removing the aspergilloma by flexible bronchoscopy was unsuccessful. The aspergilloma can be seen at bronchoscopy in Fig 4.
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Widespread mucoid impaction also seen, particularly in left side, suggestive of allergic bronchopulmonary aspergillosis.
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Microscopy of fungal hyphae isolated from fungal culture (lactophenol blue)
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A CT scan performed at this time showed an enhancing lesion with ill defined margins involving the pterigopalatine fossa, the maxillary antrum , orbital apex and middle cranial fossa. There was also destruction of boney architecture locally.
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The patient underwent a pneumonectomy because of the severity of her disease process, and uncertainty about the diagnosis, prior to serology results being obtained.
Serology showed an IgE of 2600, with a strongly positive Aspergillus RAST test and weakly positive Aspergillus precipitins. Material removed at bronchoscopy showed eosinophilia. These features confirm a diagnosis of allergic bronchopulmonary aspergillosis (ABPA).
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