Date: 26 November 2013
The patient was a 37-year old man in whom P.carinii pneumonia developed in August 1987, followed by esophageal candidiasis and upper gastrointestinal bleeding in September. Chronic perineal herpes led to the formation of rectourethral fistula and multiple episodes of urosepsis, for which he was given long-term ciprofloxacin therapy to suppress bacterial colonization of the bladder. He discontinued heavy alcohol use in September 1987 and smoked marijuana occasionally.On April 23 1989, the patient was admitted to the hospital with a two-month history of increasing dry cough with shortness of breath. He reported transient fever (temperature to 41°C). He was admitted with leukopenia, with his neutrophil count falling to 16 x 106/l on the second hospital day. A chest film showed bilateral fluffy lower-lobe infiltrates (this image). Zidovudine was discontinued. The patient had a rapidly downhill course despite intravenous treatment with trimethioprim-sulfamethoxazole. A bronchoscopy on the sixth hospital day revealed what appeared to be a foreign body in the left lower-lobe bronchus. It was removed, together with much necrotic, mucoid debris. On microscopic examination, the “foreign body” was necrotic, containing large numbers of hyphae and conidia in a manner typical of an aspegilloma or fungal cast. The culture grew A.fumigatus.
Clinical and radiologic improvement followed bronchoscopy, and itraconazole therapy was begun because of the concern about invasive aspergillosis in the setting of marked neutropenia. The patient tolerated the medication well at a dose of 200 mg twice daily, and the chest film became normal over the subsequent six weeks, after which itraconazole was discontinued. A sputum specimen cultured for fungus four weeks after the start of therapy was negative. After the initial improvement with itraconazole, the patient had recurrent urosepsis, associated with dehydration and marked confusion. Nine weeks after the discontinuation of itraconazole, he died of progressive dementia complicated by recurrent pneumonia and sepsis. There was no postmortem examination.
This patient was described (pt 11) and this chest radiograph reproduced in Denning DW, Follansbee S, Scolaro M, Norris S, Edelstein D, Stevens DA. Pulmonary Aspergillosis in the Acquired Immunodeficiency Syndrome. N Engl J Med 1991; 324: 654-662.
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Diagnosis: Aspergilloma with invasive aspergillosis evidence of invasion found in the lumbar spine and brain, in addition to heart.
Fungal endocarditis with NO evidence of bacterial endocarditismia.Additional image details:
A. Normal chest X ray:
This (normal) chest X-ray was taken about 6 weeks before endocarditis was diagnosed, and 3 months before death due to disseminated aspergillosis. No CT scan was done (a chest radiograph has a 10% false negative rate in leukaemic patients, compared with CT).B. Aspergillus niger Fungal ball:
Gross section of lung at autopsy showing a discrete, well-demarcated dark/black mass surrounded by a fibrotic capsule. There was no evidence of local invasion, or infarction. The patient had had acute myeloid leukaemia (M1) and responded poorly to chemotherapy. He developed A.niger endocarditis and disseminated disease to the kidneys, lumbar disc and heart, probably arisiong from this lesion. It is unclear whether this lung lesion was a partially cured ‘mycotic lung sequestrum’ following antifungal therapy, or originated as an aspergilloma. The confirmation of genus and species was obtained by PCR on blood and vegetations.C. Endocarditis:
Macroscopic view of the heart at autopsy, showing an infracted lesion on the papillary muscle of the mitral valve in the left ventricle. In addition the patient had large vegetations, which are not shown here. The confirmation of genus and species was obtained by PCR on blood and vegetations; the pericarditis was a manifestation of disseminated aspergillosis.D. Pericarditis due to Aspergillus niger:
Macroscopic view of the pericardium at autopsy, showing gross chronic haemorrhagic pericarditis. The confirmation of genus and species was obtained by PCR on blood and vegetations; the pericarditis was a manifestation of disseminated aspergillosis.E. Lumbar discitis:
Macroscopic lesion of a lumbar intervertebral vertebral at autopsy, showing haemorrhagic necrosis, caused by hyphal invasion and infarction. The confirmation of genus and species was obtained by PCR on blood and vegetations; the discitis was a manifestation of disseminated aspergillosis.
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Secondary metabolites, structure diagram: Trivial name – Folipastatin
