Date: 26 November 2013
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.
Copyright:
DW Denning and JE Ferguson, University Hospital of South Manchester. 22/07/08
Notes: n/a
Images library
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Late (venous) phase angiogram of a right intercostal artery showing persistence of vascular blush and further filling of a branch of the pulmonary artery.
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Catheter tip in a right posterior intercostal artery on screening film.
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Angiogram of a right bronchial artery on subtraction film in the early arterial phase showing filling hypervascular circulation superiorly and communications with a pulmonary arterial radical.
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This patient with severe pulmonary sarcoidosis has bilateral aspergillomas. A rim of air is visible around parts of the aspergillomas on both sides. This patient was recruited into the NIAID Mycoses Study Group multicentre study of the treatment of invasive pulmonary aspergillosis with itraconazole but not analysed because invasive disease was not demonstrated. Denning DW, Lee JY, Hostetler JS, Pappas P, Kauffman CA, Dewsnup DH, Galgiani JN, Graybill JR, Sugar AM, Catanzaro A, Gallis H, Perfect JR, Dockery B, Dismukes WE, Stevens DA, NIAID Mycoses Study Group multicenter trial of oral itraconazole therapy of invasive aspergillosis. Am J Med 1994; 97: 135-144
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Extensive pleural thickening is demonstrated at the left apex on this CT scan of a woman who had previously had tuberculosis and whose large cavity gradually became obliterated by pleural thickening. An aspergilloma is demonstrable within the cavity
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This chest radiograph (AMBER film) demonstrates the typical extensive pleural thickening at the right apex, seen in patients with aspergillomas. The cavity appears not to contain an aspergilloma but on CT scan had some ‘debris’ and Aspergillus antibiotics (precipitins) were strongly positive. The differential diagnosis lies between an aspergilloma and chronic invasive pulmonary aspergillosis. The extensive pleural thickening is heavily in favour of an aspergilloma, even without a well demonstrated fungal ball in the cavity.
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Image C. Another example of a severe apical aspergilloma with remarkably little pleural thickening on plain chest radiograph (AMBER film). Severe distortion of the trachea is demonstrated.
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Right apical aspergilloma, patient WC. Plain chest radiograph of patient with right apical aspergilloma in an old, large tuberculous cavity. Severe haemoptysis and respiratory insufficiency together constituted the indications for embolisation which was done in one session over a 3 hour period (see images 1-6).
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