Date: 26 November 2013
IPA in late stage AIDS, pt TB
Copyright: n/a
Notes:
Close up of cavity of left upper-lobe, proven to be invasive pulmonary aspergillosis at autopsy.
Pulmonary aspergillosis in a patient who had AIDS for 3 years (CD4 count. <10/mm3). Right middle-lobe consolidation and a left upper-lobe cavity as seen in a previously normal lung; the diagnosis was made by culture of a bronchoalveolar lavage specimen and was confirmed at autopsy. (This was published in (Khoo S, Denning DW. Aspergillus infection in the acquired immune deficiency syndrome. Clin Infect Dis 1994; 19 (suppl 1): S41-48.)
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This patient with ABPA and chronic cavitary pulmonary aspergillosis has been stabilized on voriconazole treatment for >5 years. She had a degree of photosensitivity most of that time, noticed early in the course of voriconazole treatment. She is oxygen and wheelchair dependent and doesn’t go outside very much, so most of her light exposure has been indoor light. She developed rough scaly patches over her face, neck and lower arms. Dermatological review indicated multiple solar keratoses”. Skin biopsy from the right forearm confirmed this clinical diagnosis – “skin showing hyperkeratosis with a little parakeratosis and acanthosis. The keratinocytes have a glassy appearance but show nuclear atypia with dyskeratotic cells, and occasional suprabasal mitoses. The intraepidermal sweat ducts are spared. Appearances suggest an actinic keratosis with moderate to severe dysplasia.” These features are characteristic of a low grade premalignant change.
She was treated with local 5-fluorouracil cream (Efudix) (3 cycles) to the affected lesions. These photos were taken at the apogee of inflammation. The inflammation resolved after discontinuing the cream. This reaction is expected with application of this mild chemotherapy agent. Alternative or supplementary treatments include cryotherapy, curettage and cautery, if necessary. Following treatment her skin was much softer and considerably improved. Voriconazole has been stopped, and posaconazole substituted.
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Patient NG -ocular redness and erythema due to voriconazole.
