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An unusual presentation of a pulmonary fungus ball in an immunocompromised patient
I94
Letters to the Editor
control. G r a m - s t a i n i n g of the pus revealed G r a m - p o s i t i v e branching rods and
Actinomyces israelii was subsequently isolated from it. T h e patient gave a history of penicillin-hypersensitivity and was therefore treated with intravenous clindamycin 6oo m g m q.d.s, for 5 weeks, followed by 45o m g m q.d.s, orally for 3 weeks. Following treatment, he was virtually free from pain, the chest lesion had resolved and X - r a y of the spine showed sclerosis of the previously lytic areas. T h e E S R had fallen to I7 m m / h . N o side-effects associated with the clindamycin therapy were encountered. T h i s case illustrates a rare manifestation of an unusual microbial disease. It also shows the successful treatment with clindamycin of a penicillin-sensitive patient. Actinomycosis is caused by a Gram-positive branching anaerobic bacterium. T h e organism may be found in small n u m b e r s inhabiting the mucous m e m b r a n e s of the healthy mouth. T h e disease seldom involves the vertebral column which is always invaded secondarily by extension from a p r i m a r y lesion. In our case, this was the respiratory tract. Diagnosing actinomycosis of the spine is difficult, spinal s y m p t o m s c o m m o n l y being absent. T h e disease is not likely to be recognised until an advanced stage and then is often obscured by manifestations of the p r i m a r y lesion. Previous case reports ~'4 have described the successful use of clindamycin in treating actinomycotic infection. We would agree with the authors that clindamycin is a valuable drug in this condition when dealing with a penicillin-allergic patient.
* Broomfield Hospital Court Road Chelmsford C M I 5 E T and t Public Health Laboratory New Writtle Street Chelmsford C M 2 o Y X , U.K.
H . D . L . Birley* E. L. Tearet:~ J . A . Utting*
Address correspondence to D r E. L. Teare.
References I. Cope VZ. Actinomycosis of bone with special reference to infection of the vertebral column. J Bone Joint Surg (Br) I95I; 331]: 2o5-zi4 2. Meyer M, Gall MB. Mycosis of the vertebral column : A review of the literature. J Bone Joint Surg (Br) I935; I7:857-867 3. Rose HD, Rytel MW. Actinomycosis treated with clindamycin. JAMA 1972; 2zI: IO52 4. Badgett JT, Adams G. Mandibular actinomycosis treated with oral clindamycin. Pediatr Infect Dis J I987; 221-223
An unusual presentation o f a p u l m o n a r y fungus ball in an i m m u n o c o m p r o m i s e d patient
Accepted for publication I December I988 Sir, T h e relative success of intensive chemotherapy for acute leukaemia has led to prolonged periods of immunosuppression and neutropenia with a consequent increased incidence of invasive or saprophytic fungal infection. 1 We wish to describe a dramatic and unusual presentation of a p u l m o n a r y fungus ball in such circumstances.
Letters to the Editor
I95
A 4o-year-old m a n was receiving re-induction chemotherapy for a relapse of acute myeloid leukaemia having enjoyed a 5 year first remission. During his original treatment, he had had several periods of prolonged pancytopenia. A second complete remission was achieved with a course of daunorubicin, cytosine arabinoside and 6thioguanine ( ' D A T 3 + I o ' ) . Consolidation chemotherapy was in the form of mitozantrone and m e d i u m doses of cytosine ar~binoside for 5 days. T h i s induced a 6 week period of profound pancytopenia requiring intensive support with blood products. Escherichia coli septicaemia responded well to intravenous antibiotics. After 5 weeks of neutropenia, the patient developed a low grade fever and persistent tachycardia but a focus of infection was not evident. A chest X - r a y was normal and cultures of blood, urine and s p u t u m were negative. Precipitin test for Aspergillus sp. were negative but the concentration of C-reactive protein was raised to Io4 mg/1. Five days later, he developed acute dyspnoea with cyanosis and tachycardia. Auscultation revealed a ' silent chest' but his clinical condition improved after nebulised salbutamol. Widespread expiratory wheezes were then heard. T h e peak expiratory flow rate was only ,2o 1/min but a further chest X - r a y was normal. Twelve hours later, the patient became severely breathless once again and expectorated a firm yellow-brown spherical mass of 2 cm diameter. T h i s event produced instant and p e r m a n e n t relief of all respiratory s y m p t o m s (peak flow rate 50o l/min). Our initial impression was that the mass was a food bolus but the specimen was sent for histological examination. T o our surprise microscopical examination revealed a fungus ball comprising a large mass of dead fungal elements and necrotic material with viable fungi at the edge. A portion of bronchial wall and cartilage was attached and areas of ossification were present within the tumour. F u r t h e r chest X-rays, t o m o g r a m s and a computerised tomographic ( C T ) scan of the lungs were entirely normal. Tests for Aspergillus precipitins remained negative. T h e patient subsequently remained well until a further relapse of leukaemia I5 months later. T h e clinical features in this patient suggested obstruction of a major airway by the fungus ball which may have arisen within a bronchus. Mobility of aspergillomata within lung cavities ~ and bronchial obstruction with secondary pneumonia 3 are well described but we cannot find any other description of presentation with acute respiratory obstruction. T h e absence of any radiological or C T lung abnormality is against the t u m o u r having arisen in a lung cavity. F u r t h e r m o r e , there was no subsequent evidence of invasive or disseminated fungal disease. T h e fungus involved was not precisely identified although Aspergillus sp. is probably the most likely despite the negative precipitin tests. Although rare, the presence of a mobile fungus ball should be considered in any high risk patient who develops signs of acute respiratory obstruction. (We thank Dr A. C. Andrews and Dr P. N. Cowen for the histological studies.)
General Infirmary Great George Street Leeds L S I 3 E X , U.K.
L. E. Rhodes D. R. Norfolk
References I. Gerson SL, Talbot GH, Hurwitz S, Strom BL, Lusk EJ, Cassileth PA. Prolonged granulocytopenia: the major risk factor for invasive pulmonary aspergillosis in patients with acute leukaemia. Ann Intern Med r984; xoo: 345-35I. 2. Hemphill RA. Mycotic lung infection. Am 57Med r946; x : 7o8-7o9. 3. Joynson DHM. Pulmonary aspergilloma. Br 57 Clin Pract I977; 3I: 207-216.
Letters to the Editor
control. G r a m - s t a i n i n g of the pus revealed G r a m - p o s i t i v e branching rods and
Actinomyces israelii was subsequently isolated from it. T h e patient gave a history of penicillin-hypersensitivity and was therefore treated with intravenous clindamycin 6oo m g m q.d.s, for 5 weeks, followed by 45o m g m q.d.s, orally for 3 weeks. Following treatment, he was virtually free from pain, the chest lesion had resolved and X - r a y of the spine showed sclerosis of the previously lytic areas. T h e E S R had fallen to I7 m m / h . N o side-effects associated with the clindamycin therapy were encountered. T h i s case illustrates a rare manifestation of an unusual microbial disease. It also shows the successful treatment with clindamycin of a penicillin-sensitive patient. Actinomycosis is caused by a Gram-positive branching anaerobic bacterium. T h e organism may be found in small n u m b e r s inhabiting the mucous m e m b r a n e s of the healthy mouth. T h e disease seldom involves the vertebral column which is always invaded secondarily by extension from a p r i m a r y lesion. In our case, this was the respiratory tract. Diagnosing actinomycosis of the spine is difficult, spinal s y m p t o m s c o m m o n l y being absent. T h e disease is not likely to be recognised until an advanced stage and then is often obscured by manifestations of the p r i m a r y lesion. Previous case reports ~'4 have described the successful use of clindamycin in treating actinomycotic infection. We would agree with the authors that clindamycin is a valuable drug in this condition when dealing with a penicillin-allergic patient.
* Broomfield Hospital Court Road Chelmsford C M I 5 E T and t Public Health Laboratory New Writtle Street Chelmsford C M 2 o Y X , U.K.
H . D . L . Birley* E. L. Tearet:~ J . A . Utting*
Address correspondence to D r E. L. Teare.
References I. Cope VZ. Actinomycosis of bone with special reference to infection of the vertebral column. J Bone Joint Surg (Br) I95I; 331]: 2o5-zi4 2. Meyer M, Gall MB. Mycosis of the vertebral column : A review of the literature. J Bone Joint Surg (Br) I935; I7:857-867 3. Rose HD, Rytel MW. Actinomycosis treated with clindamycin. JAMA 1972; 2zI: IO52 4. Badgett JT, Adams G. Mandibular actinomycosis treated with oral clindamycin. Pediatr Infect Dis J I987; 221-223
An unusual presentation o f a p u l m o n a r y fungus ball in an i m m u n o c o m p r o m i s e d patient
Accepted for publication I December I988 Sir, T h e relative success of intensive chemotherapy for acute leukaemia has led to prolonged periods of immunosuppression and neutropenia with a consequent increased incidence of invasive or saprophytic fungal infection. 1 We wish to describe a dramatic and unusual presentation of a p u l m o n a r y fungus ball in such circumstances.
Letters to the Editor
I95
A 4o-year-old m a n was receiving re-induction chemotherapy for a relapse of acute myeloid leukaemia having enjoyed a 5 year first remission. During his original treatment, he had had several periods of prolonged pancytopenia. A second complete remission was achieved with a course of daunorubicin, cytosine arabinoside and 6thioguanine ( ' D A T 3 + I o ' ) . Consolidation chemotherapy was in the form of mitozantrone and m e d i u m doses of cytosine ar~binoside for 5 days. T h i s induced a 6 week period of profound pancytopenia requiring intensive support with blood products. Escherichia coli septicaemia responded well to intravenous antibiotics. After 5 weeks of neutropenia, the patient developed a low grade fever and persistent tachycardia but a focus of infection was not evident. A chest X - r a y was normal and cultures of blood, urine and s p u t u m were negative. Precipitin test for Aspergillus sp. were negative but the concentration of C-reactive protein was raised to Io4 mg/1. Five days later, he developed acute dyspnoea with cyanosis and tachycardia. Auscultation revealed a ' silent chest' but his clinical condition improved after nebulised salbutamol. Widespread expiratory wheezes were then heard. T h e peak expiratory flow rate was only ,2o 1/min but a further chest X - r a y was normal. Twelve hours later, the patient became severely breathless once again and expectorated a firm yellow-brown spherical mass of 2 cm diameter. T h i s event produced instant and p e r m a n e n t relief of all respiratory s y m p t o m s (peak flow rate 50o l/min). Our initial impression was that the mass was a food bolus but the specimen was sent for histological examination. T o our surprise microscopical examination revealed a fungus ball comprising a large mass of dead fungal elements and necrotic material with viable fungi at the edge. A portion of bronchial wall and cartilage was attached and areas of ossification were present within the tumour. F u r t h e r chest X-rays, t o m o g r a m s and a computerised tomographic ( C T ) scan of the lungs were entirely normal. Tests for Aspergillus precipitins remained negative. T h e patient subsequently remained well until a further relapse of leukaemia I5 months later. T h e clinical features in this patient suggested obstruction of a major airway by the fungus ball which may have arisen within a bronchus. Mobility of aspergillomata within lung cavities ~ and bronchial obstruction with secondary pneumonia 3 are well described but we cannot find any other description of presentation with acute respiratory obstruction. T h e absence of any radiological or C T lung abnormality is against the t u m o u r having arisen in a lung cavity. F u r t h e r m o r e , there was no subsequent evidence of invasive or disseminated fungal disease. T h e fungus involved was not precisely identified although Aspergillus sp. is probably the most likely despite the negative precipitin tests. Although rare, the presence of a mobile fungus ball should be considered in any high risk patient who develops signs of acute respiratory obstruction. (We thank Dr A. C. Andrews and Dr P. N. Cowen for the histological studies.)
General Infirmary Great George Street Leeds L S I 3 E X , U.K.
L. E. Rhodes D. R. Norfolk
References I. Gerson SL, Talbot GH, Hurwitz S, Strom BL, Lusk EJ, Cassileth PA. Prolonged granulocytopenia: the major risk factor for invasive pulmonary aspergillosis in patients with acute leukaemia. Ann Intern Med r984; xoo: 345-35I. 2. Hemphill RA. Mycotic lung infection. Am 57Med r946; x : 7o8-7o9. 3. Joynson DHM. Pulmonary aspergilloma. Br 57 Clin Pract I977; 3I: 207-216.