Pt DG pseudomembranous aspergillus tracheobronchitis

Date: 1 December 2013

  • Image A. CT scan 1, one week prior to admission

  • Image B. CT scan 2, on admission

  • Image C. CT scan 3: Following 6 weeks antifungal treatment

  • Image D. CT scan 4 after 3.5 months- and one month on interferon gamma

  • Image E. Chest X ray 1 (cf CT scan 1) one week pre-admission

  • Image F. Chest X-ray 2 (cf CT Scan 2) on admission

  • Image G. Histology (H&E) of membranous material removed on bronchoscopy

  • Image H. Histology stained with GMS stain showing septate branching hyphae

  • Image I. Bronchoscopy one week after admission- improvement, with some clear areas with no secretions, less oedema than one week earlier (not shown).

  • Image J. Bronchoscopy 2 weeks after admission, much improved only local plaques in distal airways.

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This patient is a 70 yr old, obese diabetic with aortic stenosis and COPD. He was admitted in early March 09, with collapse and loss of conciousness. His lungs appeared normal at this time – CT and X-ray 1. 10 days later he was admitted with increasing shortness of breath and chest X ray (F) showing widespread patchy consolidation. CT scan (B) showed bronchial dilatation, mucus plugging, nodular and bibasal consolidation. Multiple sputum samples grew Aspergillus fumigatus. The patient required intubation and remained in ITU for 160 days.

Bronchoscopy showed plaques in the major airways with more distal airways plugged with secretions resembling “cottage cheese”.There was severe contact bleeding and oedematous mucosa (I & J). Biopsy of the plaques showed fungal hyphae with a branching pattern consistent with aspergillus infection (G & H).

The patient was initially given IV and nebulised amphotericin B whilst on doses of hydrocortisone from 100-400 mg/day. Voriconazole was added with dose optimisation, and amphotericin discontinued. The patient improved gradually with voriconazole treatment over several months and for the latter month, gamma interferon was added into his regime which further improved his CT scan although some shadowing and bronchial wall thickening was still seen (D).

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