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Fatal Pulmonary Aspergillosis Following a Farm Accident
COlOlOuoalilol II • • • CommunlctJflonl for thu aection will be publUhed tJ8 IptJCB and prfofitia permU. 'l7ae commIJntI .Iaould not exceed 350 wonla in l.ngth, with tJ mafmum offioe ,.qermce,; onefigure or table can be prim.d. ErcqfIoru mtJfI occur under parlicular drcumatanca. ConIribuflona may iraclu* commenu on arlicla publUh8d in this ".nodIt;tJl, or they mtJfI bereport» ofunique educational character. Specfjic ".",....,. to publUh .Iaould be cited in a covering letter or ~
tJI tJ
pomeript.
Ina M. Gilmore, M.D.; Carol]. Camp, M.S.; FredMic1c B. Roae, M.D.; tJnd RobertJ. Lenox, M.D.,
D.,,1mentl ofInfectiotu IJiIeGN" Patlaololfland Pulm0n4'l1 Medicine, Guthrie Medkal Cm~ StJyre, PA
Reprint requaf8: Dr. Roae, Guthrie M«lIctJl Cmter, Sayre, PenMflIvania 18890
REFERENCES
1 Lake ICB, Browne PM, Van Dyke JJ, Ayers L. Fatal disseminated
F8ta1 Pulmonary Aspergillosis following a Farm Accident
2
To tIN Editor:
3
We read with interest the recent report by Lake and assoeietes'
that short-coune corticosteroid therapy may be the only risk factor fOr developing diueminated aspergillosis. We recently cared for a previously healthy immunocompetent man with no known lung disease who developed fatal pulmonary aspergillosis after a twoweek course of corticosteroids. Unique to this case was antecedent trauma involving farm equipment. CASE REPORT
A 70-year-old farmer caught his right sleeve in the drive shaft of a manure spreader, trapping him against the machine for 15 minutes. This incident occurred on December 12, 1982. He was hospitalized for three days, for treatment of a bnchia1 plexus injury with dexamethasone [Decadron] 6 mg qid. Over the next two weeks, the Decadron was tapered to 1 mg tid. A chest radiograph on December 12showed normal Bndings. On December 31,he was re-hospitalized fOr treatment of a tbree-day bout of chest pain and cough. White blood cell count (WBC) was 20,1500 with fr1 percent neutrophils. Amibcin and ticarcillin were started. Sputum cultures showed PIflUdomontu~. On tranJfer to our hospital on January 6, the WBC count was 6,900 with 94 percent neutrophils. Chest radiograph showed bilateral 8ufFy infiltrates with bilateral nodulation, some of which were cavitated with CocaI consolidation in the right upper lobe, lingula, and right lower lobe. Antibiotics and corticosteroids were discontinued upon tranJfer. Fiberoptic bronchoscopy with biopsy of the right upper lobe revealed hyphae consistent with Aspergillus within aIveolt and in necrotic tissue. Pathologic findings were not consistent with bacterial pneumonia. AapergillfU fumigaltu was cultured from bronchial brushings. Despite amphotericin B therapy, the patient expired 24 days later secondary to respiratory insufticiency. A post-mortem examination was not pemrmed.
A.".,.alfU fumigtJlul is an indigenous inhabitant of compost and 81 a thermophile, grows well in manure. I Although conlroveny exists concerning occupational predisposition to aspergillosis,:1.4 we postulate that the prolonged entrapment in the manure spreader exposed our patient to a large inoculum of A~ conidia and was the initiating ~nt in the development of disease. Subsequent corticosteroid therapy rendered him immunoincompetent and resulted in overwhelming invasiw disease. We would suggest an addendum to the editorial comments" that a diqnosis of invasive aspergillosis be considered not only as a consequence of acquired immunodeficiency syndrome, but also in the farm worker who presents with an unusual pulmonary inBltrate and history of prolonged exposure to manure.
4 5
aspergillosis in an asthmatic patient treated with corticosteroids. Chest 1983; 83:138-39 Bennett JE. Aspergillus species. In: Mandell GL, et al, eds, Principles and practices of infectious diseases. New York: John Wtley ~ Sons, 1979: 2002 Macartney IN. Pulmonary aspergillosis: a review and description of three new cases. Thorax 1964; 19:287 Hertzog AJ, Smith TS, Gobin M. Acute pulmonary aspergillosis: report of a case. Pediatrics 1949; 4:331-35 Strieder DJ: Aspergillosis: old facts, new facts and speculations (editorial). Chest 1983; 83:4-5
7b th8 Editor: The recent editorial by Dr. Strieder (Ch8.1983; 83:4-5) may be
misleading. The author suggests that invasive aspergillosis may be seen with increasing frequency in young adults with acquired immunologic abnormalities inwlving the T-cell. Whilean increased number of other types of fimgal infections may occur when the cellmediated immune system is altered, this is probably not applicable
to Aspergillus infection. In fact, it is not the T-cea as Dr. Strieder asserts, but the neutrophil (or monocyte) which is primarily responsible i»r normal host defense against Aspergillus species. 1 Invasive aspergillosis is 20 times more frequent in acute leukemia than in lymphoma or transplant patients, the latter maladies involving T-cell dysfunction. I Cohen et aPhavedemonstrated that patients with chronic granulomatous diseue who have normal immunoglobulins and intact cell-mediated immunity haw pulmonary and osseous aspergillosis as their most common fungal infection. These patients have a neutrophil defect in generation of superoxide-free radicals which inhibits microbial Idlling once the organism is phagocytized. FurtbeJ; it is recognized that the risk of invasive aspergillosis may be the greatest in neutropenic patients, 4 and their survival is most enhanced by I'fNenalof this neutropenia alongwith inducing remission of the underlying disease. 5 Thus, it is not surprising that to date invasive aspergillosis is not commonly associated with the acquired immunedeftciency syndrome' which most often afIects homosexuals, Haitians, drug addicts, and hemo-
philiacs.
John W Peten, M.D.; tlnd G. WfllitmaAWuon, M.D., EC.C.l, ClUe/, PulmontJrv Section, Prubr/terllJn-U,..,...", ojPmMfl'VtJnia M«lIctJl Cmter, PlaIltuWpIaiG
REFERENCES 1 Atkinson G~ Israel H. Aspergillus. In: Fishman ~ eel. Update: pulmonary diseasesand diaorden. New York: McGraw-Hill, 1982 2 Levine AS, SchimpfF SC, Craw RC, YouDg RC. Hematologic malignancies and other marrow failure states: progress in the management of complicating infections. Semin Hematol 1974; 11:141 3 Cohen MS, Isturiz RE, Malech HC, et aI. Fungal infection in
tJI tJ
pomeript.
Ina M. Gilmore, M.D.; Carol]. Camp, M.S.; FredMic1c B. Roae, M.D.; tJnd RobertJ. Lenox, M.D.,
D.,,1mentl ofInfectiotu IJiIeGN" Patlaololfland Pulm0n4'l1 Medicine, Guthrie Medkal Cm~ StJyre, PA
Reprint requaf8: Dr. Roae, Guthrie M«lIctJl Cmter, Sayre, PenMflIvania 18890
REFERENCES
1 Lake ICB, Browne PM, Van Dyke JJ, Ayers L. Fatal disseminated
F8ta1 Pulmonary Aspergillosis following a Farm Accident
2
To tIN Editor:
3
We read with interest the recent report by Lake and assoeietes'
that short-coune corticosteroid therapy may be the only risk factor fOr developing diueminated aspergillosis. We recently cared for a previously healthy immunocompetent man with no known lung disease who developed fatal pulmonary aspergillosis after a twoweek course of corticosteroids. Unique to this case was antecedent trauma involving farm equipment. CASE REPORT
A 70-year-old farmer caught his right sleeve in the drive shaft of a manure spreader, trapping him against the machine for 15 minutes. This incident occurred on December 12, 1982. He was hospitalized for three days, for treatment of a bnchia1 plexus injury with dexamethasone [Decadron] 6 mg qid. Over the next two weeks, the Decadron was tapered to 1 mg tid. A chest radiograph on December 12showed normal Bndings. On December 31,he was re-hospitalized fOr treatment of a tbree-day bout of chest pain and cough. White blood cell count (WBC) was 20,1500 with fr1 percent neutrophils. Amibcin and ticarcillin were started. Sputum cultures showed PIflUdomontu~. On tranJfer to our hospital on January 6, the WBC count was 6,900 with 94 percent neutrophils. Chest radiograph showed bilateral 8ufFy infiltrates with bilateral nodulation, some of which were cavitated with CocaI consolidation in the right upper lobe, lingula, and right lower lobe. Antibiotics and corticosteroids were discontinued upon tranJfer. Fiberoptic bronchoscopy with biopsy of the right upper lobe revealed hyphae consistent with Aspergillus within aIveolt and in necrotic tissue. Pathologic findings were not consistent with bacterial pneumonia. AapergillfU fumigaltu was cultured from bronchial brushings. Despite amphotericin B therapy, the patient expired 24 days later secondary to respiratory insufticiency. A post-mortem examination was not pemrmed.
A.".,.alfU fumigtJlul is an indigenous inhabitant of compost and 81 a thermophile, grows well in manure. I Although conlroveny exists concerning occupational predisposition to aspergillosis,:1.4 we postulate that the prolonged entrapment in the manure spreader exposed our patient to a large inoculum of A~ conidia and was the initiating ~nt in the development of disease. Subsequent corticosteroid therapy rendered him immunoincompetent and resulted in overwhelming invasiw disease. We would suggest an addendum to the editorial comments" that a diqnosis of invasive aspergillosis be considered not only as a consequence of acquired immunodeficiency syndrome, but also in the farm worker who presents with an unusual pulmonary inBltrate and history of prolonged exposure to manure.
4 5
aspergillosis in an asthmatic patient treated with corticosteroids. Chest 1983; 83:138-39 Bennett JE. Aspergillus species. In: Mandell GL, et al, eds, Principles and practices of infectious diseases. New York: John Wtley ~ Sons, 1979: 2002 Macartney IN. Pulmonary aspergillosis: a review and description of three new cases. Thorax 1964; 19:287 Hertzog AJ, Smith TS, Gobin M. Acute pulmonary aspergillosis: report of a case. Pediatrics 1949; 4:331-35 Strieder DJ: Aspergillosis: old facts, new facts and speculations (editorial). Chest 1983; 83:4-5
7b th8 Editor: The recent editorial by Dr. Strieder (Ch8.1983; 83:4-5) may be
misleading. The author suggests that invasive aspergillosis may be seen with increasing frequency in young adults with acquired immunologic abnormalities inwlving the T-cell. Whilean increased number of other types of fimgal infections may occur when the cellmediated immune system is altered, this is probably not applicable
to Aspergillus infection. In fact, it is not the T-cea as Dr. Strieder asserts, but the neutrophil (or monocyte) which is primarily responsible i»r normal host defense against Aspergillus species. 1 Invasive aspergillosis is 20 times more frequent in acute leukemia than in lymphoma or transplant patients, the latter maladies involving T-cell dysfunction. I Cohen et aPhavedemonstrated that patients with chronic granulomatous diseue who have normal immunoglobulins and intact cell-mediated immunity haw pulmonary and osseous aspergillosis as their most common fungal infection. These patients have a neutrophil defect in generation of superoxide-free radicals which inhibits microbial Idlling once the organism is phagocytized. FurtbeJ; it is recognized that the risk of invasive aspergillosis may be the greatest in neutropenic patients, 4 and their survival is most enhanced by I'fNenalof this neutropenia alongwith inducing remission of the underlying disease. 5 Thus, it is not surprising that to date invasive aspergillosis is not commonly associated with the acquired immunedeftciency syndrome' which most often afIects homosexuals, Haitians, drug addicts, and hemo-
philiacs.
John W Peten, M.D.; tlnd G. WfllitmaAWuon, M.D., EC.C.l, ClUe/, PulmontJrv Section, Prubr/terllJn-U,..,...", ojPmMfl'VtJnia M«lIctJl Cmter, PlaIltuWpIaiG
REFERENCES 1 Atkinson G~ Israel H. Aspergillus. In: Fishman ~ eel. Update: pulmonary diseasesand diaorden. New York: McGraw-Hill, 1982 2 Levine AS, SchimpfF SC, Craw RC, YouDg RC. Hematologic malignancies and other marrow failure states: progress in the management of complicating infections. Semin Hematol 1974; 11:141 3 Cohen MS, Isturiz RE, Malech HC, et aI. Fungal infection in