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Invasive pulmonary aspergillosis complicated by pulmonary artery occlusion in an immunocompetent patient
Clinical Radiology (2006) 61, 287–290
CASE REPORT
Invasive pulmonary aspergillosis complicated by pulmonary artery occlusion in an immunocompetent patient S. Chonga, T.S. Kima,*, W.-J. Kohb, E.Y. Choc, K. Kimd a
Department of Radiology and Center for Imaging Science, bDivision of Pulmonary and Critical Care Medicine, Department of Medicine, Departments of cPathology, and dThoracic Surgery and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, South Korea
Introduction Invasive pulmonary aspergillosis manifests as one of four major clinicopathological forms: acute bronchopneumonia, acute tracheobronchitis, angioinvasive aspergillosis, and chronic necrotizing aspergillosis.1 These manifestations of invasive pulmonary aspergillosis depend on the patient’s underlying immune status.2 Angioinvasive aspergillosis is the most common form of invasive pulmonary aspergillosis, and is typically seen in patients with acute leukaemia, whereas chronic necrotizing aspergillosis is relatively rare and usually slowly progressive, and often occurs in patients with underlying chronic pulmonary disease or in mildly immunocompromised patients. 1 Several case reports of invasive pulmonary aspergillosis complicated by vascular occlusion in immunocompromised patients have been published.3–5 To our knowledge, however, such a case in an immunocompetent patient has not previously been reported in the literature. We present a case of invasive pulmonary aspergillosis complicated by pulmonary artery occlusion in an immunocompetent patient.
Case report A 44-year-old man presenting with dyspnoea and productive cough for 1 month was admitted to * Correspondent: T.S. Kim, Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-dong, Gangnam-gu, Seoul 135-710, South Korea. Tel.: C82 2 3410 2518; fax: C82 2 3410 2559. E-mail address: [email protected] (T.S. Kim).
a local hospital. He was healthy and human immunodeficiency virus (HIV)-negative with no history of surgery, malignancy, diabetes, chronic obstructive pulmonary disease, steroid treatment or intravenous drug abuse. Contrast-enhanced chest computed tomography (CT) obtained at the local hospital showed a heterogeneously enhancing, mass-like consolidation in the left lower lobe, which consisted of an airspace consolidation and a contiguous large filling defect within the lumen of the left lower lobe pulmonary artery, raising the possibility of pulmonary thromboembolism or pulmonary artery sarcoma (Fig. 1). However, there was no evidence of deep vein thrombosis on the Doppler ultrasonography for lower extremities. For further evaluation, he underwent a bronchoscopic biopsy, which revealed chronic necrotizing granulomatous inflammation containing numerous fungal hyphae. A diagnosis of invasive pulmonary aspergillosis was made, and an antifungal agent (amphotericin B) was administrated intravenously. However, the antifungal therapy had to be discontinued after 5 consecutive days because of nephrotoxicity. Nevertheless, his symptoms and chest radiographic findings had improved without any further medical treatment during the follow-up period of 4 months. After which time, the patient developed a cough and chest discomfort. He was subsequently referred to our institute for further evaluation and treatment. At admission, his white blood cell count was normal at 4800 cells/ml with 57% polymorphonuclear leukocytes. Differential blood eosinophil count was elevated to 19%. On contrast-enhanced chest CT, obtained at our institute, the previous airspace consolidation in the left lower lobe decreased markedly in extent, but the intraluminal
0009-9260/$ - see front matter Q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2005.11.006
288
S. Chong et al.
Figure 2 Oblique coronal reformation image of contrast-enhanced CT obtained 4 months later demonstrates the longitudinal extent of the persistent filling defect (arrowheads) within the left lower lobe pulmonary artery.
Figure 1 A 44-year-old man with invasive pulmonary aspergillosis. Initial axial contrast-enhanced chest CT image, obtained at a local hospital, demonstrates a heterogeneously enhancing consolidation with a contiguous tumour thrombus (arrowheads) occupying the lumen of the left lower lobe pulmonary artery.
The architecture of the arterial wall was disrupted in part by the chronic inflammatory process. After surgery, he recovered uneventfully, and had no evidence of local recurrence for 4 months.
Discussion filling defect within the left lower lobe pulmonary artery had persisted (Fig. 2). For the purpose of confirmative diagnosis and treatment, a left lower lobectomy using video-assisted thoracoscopic surgery was performed. Grossly, a whitish, firm, intravascular mass was found within the lumen of the left lower lobe pulmonary artery associated with a small area of contiguous parenchymal consolidation containing pus-like material. Multiple subsegmental consolidations were also seen in the subpleural lung of the left lower lobe, suggestive of pulmonary infarction and necrosis. A histopathological examination of the intravascular mass and the contiguous parenchymal consolidation revealed chronic necrotizing granulomatous inflammation, containing numerous, acutely branching fungal hyphae consistent with Aspergillus (Figs. 3 and 4).
Pulmonary diseases associated with Aspergillus depend on the patient’s immune status and underlying lung disease; aspergilloma in immunocompetent patients, chronic necrotizing aspergillosis (also known as semi-invasive aspergillosis) in mildly immunosuppressed patients, invasive pulmonary aspergillosis in immunocompromised patients, and allergic bronchopulmonary aspergillosis in hypersensitive patients are well-known manifestations of pulmonary aspergillosis in relation to patients’ immune status.1 Recently, in reports of pulmonary aspergillosis in immunocompetent hosts, Kang et al.6 and Ko et al.7 reported that the radiological findings of pulmonary aspergillosis included a single nodule or mass with or without an air crescent, a localized consolidation, multifocal consolidation, large masses, and nodules with ground-glass haloes. To our knowledge,
Invasive pulmonary aspergillosis complicated by pulmonary artery occlusion
Figure 3 Photomicrograph of the intravascular mass in the lobectomy specimen shows a necrotic thrombus within the lumen of the pulmonary artery, which correlates well with (2), the coronal reformation CT image. The architecture of the arterial wall is disrupted in part by the chronic inflammatory process (arrowheads; periodic acid Schiff stain, !1).
289
however, a case of invasive pulmonary aspergillosis complicated by vascular occlusion in an immunocompetent patient has not yet been reported in the literature. In invasive pulmonary aspergillosis, vascular permeation by fungal hyphae can occur in the clinicopathological forms such as angioinvasive aspergillosis and chronic necrotizing aspergillosis. In the former, there is extensive vascular permeation by fungal hyphae with occlusion of small arteries resulting in haemorrhagic infarction mostly in a neutropenic patient; a thrombus may or may not be present.1 Conversely, the latter shows granulomatous inflammation and necrosis mostly in a mildly immunocompromised patient with rare vascular invasion by fungal hyphae.3–5 In the present case, the thrombus consisting of inflammatory cells and fungal hyphae developed from direct invasion of the arterial wall by contiguous chronic necrotizing aspergillosis in an immunocompetent patient. In a case report of invasive pulmonary aspergillosis involving the thoracic aorta, Katz et al.4 recommended that the diagnosis of invasive pulmonary aspergillosis should be considered when a vascular intraluminal mass is detected, particularly in a neutropenic or immunocompromised patient. As the present case shows, invasive pulmonary aspergillosis should be considered even in an immunocompetent patient when a vascular intraluminal mass associated with contiguous airspace consolidation is detected using contrast-enhanced CT. In summary, a case of invasive pulmonary aspergillosis is reported in an immunocompetent patient, in which chronic necrotizing aspergillosis was complicated by direct invasion of the infection into an adjacent pulmonary artery and thrombus formation with luminal occlusion. We suggest that the possibility of invasive pulmonary aspergillosis should be raised when pulmonary thromboembolic disease associated with contiguous chronic pneumonia is seen using CT even in an immunocompetent patient.
References
Figure 4 Higher magnification photomicrograph of the thrombus in (3) shows chronic necrotizing granulomatous inflammation consisting of histiocytes and multinucleated giant cells surrounding a collection of neutrophils. Note numerous, acutely branching fungal hyphae consistent with Aspergillus (arrowheads; periodic acid Schiff stain, !100).
1. Fraser RS, Colman N, Mu ¨ller NL, Pare PD. Infectious disease of the lungs. 3rd ed. Synopsis of diseases of the chest. Philadelphia: Elsevier Saunders; 2005 p. 222–336. 2. Aquino SL, Kee ST, Warnock ML, Gamsu G. Pulmonary aspergillosis: imaging findings with pathologic correlation. AJR Am J Roentgenol 1994;163:811—5. 3. Hayashi H, Takagi R, Onda M, Kumazaki T. Invasive pulmonary aspergillosis occluding the descending aorta and left pulmonary artery: CT features. J Comput Assist Tomogr 1994;18: 492—4.
290
4. Katz JF, Yassa NA, Bhan I, Bankoff MS. Invasive aspergillosis involving the thoracic aorta: CT appearance. AJR Am J Roentgenol 1994;163:817—9. 5. Hashino S, Imamura M, Tanaka J, et al. Invasive pulmonary aspergillosis complicated by subclavian artery occlusion following allogeneic stem cell transplantation. Acta Haematol 1997;98:167—9.
S. Chong et al.
6. Kang EY, Kim DH, Woo OH, Choi JA, Oh YW, Kim CH. Pulmonary aspergillosis in immunocompetent hosts without underlying lesions of the lung: radiologic and pathologic findings. AJR Am J Roentgenol 2002;178:1395—9. 7. Ko JP, Kim DH, Shepard JA. Pulmonary aspergillosis in an immunocompetent patient. J Thorac Imaging 2002; 17:70—3.
CASE REPORT
Invasive pulmonary aspergillosis complicated by pulmonary artery occlusion in an immunocompetent patient S. Chonga, T.S. Kima,*, W.-J. Kohb, E.Y. Choc, K. Kimd a
Department of Radiology and Center for Imaging Science, bDivision of Pulmonary and Critical Care Medicine, Department of Medicine, Departments of cPathology, and dThoracic Surgery and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, South Korea
Introduction Invasive pulmonary aspergillosis manifests as one of four major clinicopathological forms: acute bronchopneumonia, acute tracheobronchitis, angioinvasive aspergillosis, and chronic necrotizing aspergillosis.1 These manifestations of invasive pulmonary aspergillosis depend on the patient’s underlying immune status.2 Angioinvasive aspergillosis is the most common form of invasive pulmonary aspergillosis, and is typically seen in patients with acute leukaemia, whereas chronic necrotizing aspergillosis is relatively rare and usually slowly progressive, and often occurs in patients with underlying chronic pulmonary disease or in mildly immunocompromised patients. 1 Several case reports of invasive pulmonary aspergillosis complicated by vascular occlusion in immunocompromised patients have been published.3–5 To our knowledge, however, such a case in an immunocompetent patient has not previously been reported in the literature. We present a case of invasive pulmonary aspergillosis complicated by pulmonary artery occlusion in an immunocompetent patient.
Case report A 44-year-old man presenting with dyspnoea and productive cough for 1 month was admitted to * Correspondent: T.S. Kim, Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-dong, Gangnam-gu, Seoul 135-710, South Korea. Tel.: C82 2 3410 2518; fax: C82 2 3410 2559. E-mail address: [email protected] (T.S. Kim).
a local hospital. He was healthy and human immunodeficiency virus (HIV)-negative with no history of surgery, malignancy, diabetes, chronic obstructive pulmonary disease, steroid treatment or intravenous drug abuse. Contrast-enhanced chest computed tomography (CT) obtained at the local hospital showed a heterogeneously enhancing, mass-like consolidation in the left lower lobe, which consisted of an airspace consolidation and a contiguous large filling defect within the lumen of the left lower lobe pulmonary artery, raising the possibility of pulmonary thromboembolism or pulmonary artery sarcoma (Fig. 1). However, there was no evidence of deep vein thrombosis on the Doppler ultrasonography for lower extremities. For further evaluation, he underwent a bronchoscopic biopsy, which revealed chronic necrotizing granulomatous inflammation containing numerous fungal hyphae. A diagnosis of invasive pulmonary aspergillosis was made, and an antifungal agent (amphotericin B) was administrated intravenously. However, the antifungal therapy had to be discontinued after 5 consecutive days because of nephrotoxicity. Nevertheless, his symptoms and chest radiographic findings had improved without any further medical treatment during the follow-up period of 4 months. After which time, the patient developed a cough and chest discomfort. He was subsequently referred to our institute for further evaluation and treatment. At admission, his white blood cell count was normal at 4800 cells/ml with 57% polymorphonuclear leukocytes. Differential blood eosinophil count was elevated to 19%. On contrast-enhanced chest CT, obtained at our institute, the previous airspace consolidation in the left lower lobe decreased markedly in extent, but the intraluminal
0009-9260/$ - see front matter Q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2005.11.006
288
S. Chong et al.
Figure 2 Oblique coronal reformation image of contrast-enhanced CT obtained 4 months later demonstrates the longitudinal extent of the persistent filling defect (arrowheads) within the left lower lobe pulmonary artery.
Figure 1 A 44-year-old man with invasive pulmonary aspergillosis. Initial axial contrast-enhanced chest CT image, obtained at a local hospital, demonstrates a heterogeneously enhancing consolidation with a contiguous tumour thrombus (arrowheads) occupying the lumen of the left lower lobe pulmonary artery.
The architecture of the arterial wall was disrupted in part by the chronic inflammatory process. After surgery, he recovered uneventfully, and had no evidence of local recurrence for 4 months.
Discussion filling defect within the left lower lobe pulmonary artery had persisted (Fig. 2). For the purpose of confirmative diagnosis and treatment, a left lower lobectomy using video-assisted thoracoscopic surgery was performed. Grossly, a whitish, firm, intravascular mass was found within the lumen of the left lower lobe pulmonary artery associated with a small area of contiguous parenchymal consolidation containing pus-like material. Multiple subsegmental consolidations were also seen in the subpleural lung of the left lower lobe, suggestive of pulmonary infarction and necrosis. A histopathological examination of the intravascular mass and the contiguous parenchymal consolidation revealed chronic necrotizing granulomatous inflammation, containing numerous, acutely branching fungal hyphae consistent with Aspergillus (Figs. 3 and 4).
Pulmonary diseases associated with Aspergillus depend on the patient’s immune status and underlying lung disease; aspergilloma in immunocompetent patients, chronic necrotizing aspergillosis (also known as semi-invasive aspergillosis) in mildly immunosuppressed patients, invasive pulmonary aspergillosis in immunocompromised patients, and allergic bronchopulmonary aspergillosis in hypersensitive patients are well-known manifestations of pulmonary aspergillosis in relation to patients’ immune status.1 Recently, in reports of pulmonary aspergillosis in immunocompetent hosts, Kang et al.6 and Ko et al.7 reported that the radiological findings of pulmonary aspergillosis included a single nodule or mass with or without an air crescent, a localized consolidation, multifocal consolidation, large masses, and nodules with ground-glass haloes. To our knowledge,
Invasive pulmonary aspergillosis complicated by pulmonary artery occlusion
Figure 3 Photomicrograph of the intravascular mass in the lobectomy specimen shows a necrotic thrombus within the lumen of the pulmonary artery, which correlates well with (2), the coronal reformation CT image. The architecture of the arterial wall is disrupted in part by the chronic inflammatory process (arrowheads; periodic acid Schiff stain, !1).
289
however, a case of invasive pulmonary aspergillosis complicated by vascular occlusion in an immunocompetent patient has not yet been reported in the literature. In invasive pulmonary aspergillosis, vascular permeation by fungal hyphae can occur in the clinicopathological forms such as angioinvasive aspergillosis and chronic necrotizing aspergillosis. In the former, there is extensive vascular permeation by fungal hyphae with occlusion of small arteries resulting in haemorrhagic infarction mostly in a neutropenic patient; a thrombus may or may not be present.1 Conversely, the latter shows granulomatous inflammation and necrosis mostly in a mildly immunocompromised patient with rare vascular invasion by fungal hyphae.3–5 In the present case, the thrombus consisting of inflammatory cells and fungal hyphae developed from direct invasion of the arterial wall by contiguous chronic necrotizing aspergillosis in an immunocompetent patient. In a case report of invasive pulmonary aspergillosis involving the thoracic aorta, Katz et al.4 recommended that the diagnosis of invasive pulmonary aspergillosis should be considered when a vascular intraluminal mass is detected, particularly in a neutropenic or immunocompromised patient. As the present case shows, invasive pulmonary aspergillosis should be considered even in an immunocompetent patient when a vascular intraluminal mass associated with contiguous airspace consolidation is detected using contrast-enhanced CT. In summary, a case of invasive pulmonary aspergillosis is reported in an immunocompetent patient, in which chronic necrotizing aspergillosis was complicated by direct invasion of the infection into an adjacent pulmonary artery and thrombus formation with luminal occlusion. We suggest that the possibility of invasive pulmonary aspergillosis should be raised when pulmonary thromboembolic disease associated with contiguous chronic pneumonia is seen using CT even in an immunocompetent patient.
References
Figure 4 Higher magnification photomicrograph of the thrombus in (3) shows chronic necrotizing granulomatous inflammation consisting of histiocytes and multinucleated giant cells surrounding a collection of neutrophils. Note numerous, acutely branching fungal hyphae consistent with Aspergillus (arrowheads; periodic acid Schiff stain, !100).
1. Fraser RS, Colman N, Mu ¨ller NL, Pare PD. Infectious disease of the lungs. 3rd ed. Synopsis of diseases of the chest. Philadelphia: Elsevier Saunders; 2005 p. 222–336. 2. Aquino SL, Kee ST, Warnock ML, Gamsu G. Pulmonary aspergillosis: imaging findings with pathologic correlation. AJR Am J Roentgenol 1994;163:811—5. 3. Hayashi H, Takagi R, Onda M, Kumazaki T. Invasive pulmonary aspergillosis occluding the descending aorta and left pulmonary artery: CT features. J Comput Assist Tomogr 1994;18: 492—4.
290
4. Katz JF, Yassa NA, Bhan I, Bankoff MS. Invasive aspergillosis involving the thoracic aorta: CT appearance. AJR Am J Roentgenol 1994;163:817—9. 5. Hashino S, Imamura M, Tanaka J, et al. Invasive pulmonary aspergillosis complicated by subclavian artery occlusion following allogeneic stem cell transplantation. Acta Haematol 1997;98:167—9.
S. Chong et al.
6. Kang EY, Kim DH, Woo OH, Choi JA, Oh YW, Kim CH. Pulmonary aspergillosis in immunocompetent hosts without underlying lesions of the lung: radiologic and pathologic findings. AJR Am J Roentgenol 2002;178:1395—9. 7. Ko JP, Kim DH, Shepard JA. Pulmonary aspergillosis in an immunocompetent patient. J Thorac Imaging 2002; 17:70—3.