Segmental resection of the lung for aspergillosis

SEGMENTAL RESECTION OF THE LUNG FOR ASPERGILLOSIS” LEW A. HOCHBERG,

M.D.,

E. HARRISON

GRIFFIN,

M.D. AND ALFRED

D. BICUNAS, M.D.

Brooklyn, New York ULMONARY segmenta resection and have been found to predispose to puImonary Iobectomy have become fairly common aspergiIIosis.‘~8~‘O~‘~~r~Pulmonary tubercuIosis procedures in the treatment of localized primary cancer of the lung, bronchial asthma conditions of the Iung. It has been empIoyed and other chronic pulmonary infections are chiefIy in cases of chronic pulmonary disease local lesions which on rare occasions were comin which other modalities have faiIed to yield plicated by aspergiIIosis. satisfactory resuIts. In the case presented CASE REPORT herein we were disposed to perform a segmental F. B. (Hospital No. 38574), a forty-eight resection because of the Iocalized chronic puImonary disease which faiIed to respond to other year oId white mate, was admitted to Kings therapeutic measures and because of the recurCounty Hospital on August 24, ‘g-16. He dated rent and uncontroIIabIe hemoptyses. After the onset of his iIIness to February, 1945, when remova of the diseased lung tissue much to our he inhaled some soap powder while at work. astonishment the cause of the patient’s infirmImmediately after this episode he had a severe spasm of cough Iasting for about half an hour. ity was found to be the result of an “aspergillus For the foIlowing ten days he had a productive infestation.” The Aspergillus was first described by MicheIi cough and expectoration of a large amount of mucoid sputum. About two weeks after the onin 1725.~ Hugh Bennett (I@) is reputed to set of his iIIness he noticed some streaks of have been the first to report a case of pulmobIood in his sputum. On hlarch 15, 1915, he had nary aspergiIIosis.6120 A few years later Rudolf severe hemoptysis, coughing up about I pint Virchow (I 856) performed the first autopsy on of bIood. An x-ray of the chest taken sometime a patient having aspergillosis of the Iung. On thereafter was interpreted as indicative of acthe basis of their observations in several cases DieuIafoy, Chautemesse and Wida15 in 1890 tive puImonary tubercuIosis of the Ieft Iung. AccordingIy, he \vas admitted to a hospital on described the cIinica1 aspects of this disease. JuIy 6, 1945. Here numerous studies of sputum Their cases occurred among persons employed faiIed to show the presence of tubercle bacilli. to fatten pigeons for the Paris markets. In the Several cuItures of sputum were also negative course of their chores these attendants wouId for fungi. After a year’s stay at this hospita1 he hoId contaminated feed in their mouths and was discharged unimproved and without a force it into the mouths of the pigeons. Pulmonary aspergiIIosis is a rare disease aIdefinitive diagnosis. He continued to have rethough AspergiIIi are widespread in nature and current hemoptyses of varying severity. He are abundant in soi1. It has been postulated by did not return to work because he feared exermany writers that massive and repeated doses tion would provoke further bleeding. Two days prior to readmission to Kings of the organism are necessary before pulmonary aspergiIIosis is produced.2~4~11~‘“~15~~7~~” Even County Hospital the patient had sudden and under these conditions the disease does not profuse bIeeding from the Iung so that within occur unless IocaI or constitutional resistance is eight hours he Iost 2 to 3 pints of bIood. In Iowered for a long time. This has prompted addition to the aforementioned the patient gave a history of having diabetes mellitus for some investigators to speak of the infestation as a “secondary” disease. Constitutiona disabout tweIve years which was controlled by turbances which lower the general resistance 01 daily doses of ten units of protamin-zinc insulin the patient such as carcinomatosis, dysentery, and ten units of regular insulin. At the time of enteritis and uncontroIIed diabetes meIIitus the patient’s admission to Kings County Hospi* From the Department of Thoracic Surgery, Kings County Hospital, Brooklyn, N. Y.

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2

F~ti. I. Roentgenogr;ml of the chest taken shortly after admission to the hospital. FIG. 2. Roentgenogram of the chest taken about ten months after operation.

tal the only positive physical findings were fine, moist rales at the end of inspiration in the apex of the left lung both anteriorIy and posteriorly. An x-ray of the chest taken shortIy after admission reveaIed an area of infiltration in the left clavicular region toward the periphery of which there was a small cavity. The Iesion was highly suspicious of tuberculosis. (Fig. I .) The Wassermann test was negative. The fasting bIood sugar was 168 mg. per cent. Bronchoscopy reveaIed slight reddening of the left main bronchus. Many casual and concentrated sputa were negative for tubercIe haciIIi. Several sputa were negative for fungi. While at the hospita1 the patient continued to have moderately severe hemoptyses necessitating repeated blood transfusions. When active bleeding diminished and the sputum was only blood streaked, the patient was considered for surgical therapy. It was the opinion of the surgical staff that in view of the localized pathologic condition in the upper lobe of the left lung and the persistence of hemoptyses for over twenty months the patient would be benefited by resection of the diseased lung tissue. Accordingly, on November 14, 1946, under general endotracheal anesthesia an exploratory thoracotomy was performed. Many dorsal and apical adhesions were found which were readily di-

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vided. The anterior segment of the upper Iobe was dark red, indurated and much firmer than the surrounding lung tissue. The segment was resected after isolating the branch bronchus and vesseIs to this part of the lung tissue. The postoperative course was uneventful, the patient’s temperature rising to ror.4’F. on the first and second postoperative days and returning to normal on the seventh postoperative day. The patient was out of bed on the third postoperative day. Penicillin was given intramuscularly until the ninth day after surgical intervention. During the postoperative period the diabetes meIIitus was readiIy controlled by diet and insulin. The patient was discharged to the Thoracic SurgicaI Clinic on December 24, 1946, and was seen periodically in the clinic for a year. There has been no pulmonary bleeding since the day of surgical intervention. Kepeated examination and cuIture of the sputa have been negative for Aspergilli. Several follow-up roentgenographic examination of the chest have failed to reveal any pulmonary infiltration. (Fig. 2.) His general health has remained good and he has returned to work without any deleterious effects. The pathologic report on the tissue removed at the time of operation revealed the following: The microscopic examination showed markedly

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FLG. 3. Photomicrograph of t3he pulmonary ary inff ammatory changes; magnification FIG. 4. Photomicrograph of the puImonary

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infestatbi

and surrounding

second-

X.

fieId showing the AspergiIIus infestation;

thickened pIeura composed of dense, hyaIinized, fibrous tissue. The bronchi and bronchioIes were widely diIated; the mucosa showed patchy areas of necrosis. Within the Iumen of one bronchus there was a Iarge matted coIIection of septate myceIia among which were numerous poIymorphonucIear Ieukocytes. Many conidiophores were present, each consisting of an unbranched, non-septate hypha with a termina1 swoIIen tip or vesicIe at the summit, of which conidia were noted. The bronchia waIIs showed interstitia1 hemorrhage, fibrobIastic edema, proIiferation and a dense, diffuse infiItrate of Iymphocytes, pIasma ceIIs and poIymorphonucIear Ieukocytes. (Fig. 3.) The diagnosis was puImonary aspergiIIosis. (Fig. 4.) COMMENT

Graham, Singer and BaIlon state that up to rg3S there had been no case reported in the Iiterature in which pulmonary resection had been undertaken for aspergiIIosis. They add that “the appIication of surgica1 methods may be found to be vaIuabIe.” A review of the Iiterature since 1935 faiIs to revea1 any cases in which Iung tissue was removed for aspergiIIosis. The onset of puImonary aspergiIIosis is very insidious. There are no distinctive cIinica1 features or signs. The disease simuIates a variety of puImonary Iesions so that its cIinica1 identity is even more diffIcuIt. It is most often confused with pulmonary tubercuIosis both cIinicaIIy and on roentgenograms. In a11 patients whose x-rays revea1 changes suggestive of puImonary tubercuIosis and whose sputa are repeatedIy negative for tubercIe baciIIi, fungus

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infection of the Iung must be considered. Bronchoscopic aspirations of the bronchus leading to the pathologic area should be studied for organisms. It is also significant that patients with pulmonary aspergiIIosis are generaIIy in better physica condition than those with puImonary tubercuIosis despite repeated hemoptyses. The Iesions occurring in puImonary aspergiIIosis are divided into the superficia1 form and the deep or uIcerative form. The superficia1 form is benign and cIinicaIIy simuIates an upper respiratory infection or bronchitis. The symptoms consist of a low grade fever, paroxysms of cough and the production of smaI1 amounts of tenacious mucoid sputum. In the more acute stage it may simuIate pneumonia. The deep or ulcerative form presents many of the characteristics of puImonary tubercuIosis, often appearing as an exudative, caseous pneumonia or chronic productive tubercuIosis. Because it mimics tuberculosis, it is often referred to as “pseudotubercuIosis”17 and accounts for the Iarge number of these patients being “discovered” in tubercuIosis sanitoriums.10,11*13,15,17 SUMMARY

AND

CONCLUSIONS

A case is presented in which segmenta resection of the Iung was performed for pulmonary aspergiIIosis. One year after the patient was operated upon there was no recurrence of puImonary bIeeding nor roentgenographic evidence of pulmonary disease. Primary puImonary aspergiIIosis is a rare disease. It can be diagnosed onIy after thorough investigation.

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Secondary pulmonary aspergil1osi.s is common. Here the treatment shouId be directed toward the primary disease. Resection of the pulmonary tissue is vaIid treatment in cases of IocaIized puImonary aspergillosis. REFERENCES r. CLELAND, J. B. AspergiIIosis of pleura with scIero-

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‘924. COE, G. C. Primary broncho-ptdmonary aspergiIIosis. Ann. Int. Med., 25: 423-425, 1945. CONANT, N. F., MARTIN, D. S., SMITH, D. T., BAKER, R. D. and CALLAWAY, J. L. Manual of Medical Mycology. Chapt. I 2. Philadelphia, 1944. W. B. Saunders Co. CRAVEN, E. B. The role of aspergilli and the moniliae in chronic non-tubercuIous pulmonary disease, with and without asthma. Soutb. M. eY S., 97: 678-681, 1935. DIEULAFOY, CHAUTEMESSEand WIDAL. Un PseudotubercuIose Mycotique. Gaz. de H6p., 63: 821, 1890. DODGE, C. W. MedicaI MycoIogy. St. Louis, 1935. C. V. Mosby Co. DONALDSON,J. M., KOERTH, C. J. and MCCORKLE, R. G. Pulmonary aspergiIIosis. J. Lab. u Clin. Med., 27: 740-746, 1943. EDWARDS, J. C. A baflhng case of puImonary carcinomatosis. New England J. Med., 213: 1518, 1935.

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9. GRAHAM, E. A., SINGER, J. J. and BALLON, II. C. SurgicaI Diseases of the Chest. PhiIadeIphia, 1935. Lea and Febiger. IO. HAMMAN, L. The clinical manifestations of pneumonomycosis. Am. Rev. Tuberc., 16: 575-583, 1927. I I. HETHERINGTON, L. H. Primary aspergiIIosis of lungs. Am. Rev. Tuberc., 47: 107-108, 1943. 12. LAPHAM, M. E. AspergiIIosis of lungs and its association with tubercuIosis. J. A. M. A., 87: ro311032, 1926. 13. MOOLTON, S. E. A case of primary broncho-pulmonary aspergiIIosis. J. Mt. Sinai Hosp., 5: 2935, 1938. 14. R~NON, L. Etude sur I’AspergiIIose chez Ies Animaux et chez I’Homme. Thesis, Paris, 1897. ‘5. SCHNEIDER, L. V. Primary aspergillosis of lungs. Am. Rev. Tuberc., 22: 267-270, 1930. 16. SMITH, W. R. AspergiIIosis. J. Tennessee M. A., 27: 407-408, 1934. 17. STOLOW, A. J. Primary broncho-puImonary aspergiIIosis. J. M. Sot. New Jersey, 36: 484-485, 1~39. 18. THOM, C. and RAPER, K. B. A ManuaI of Aspergilli. Baltimore, 1945. WiIIiams & WiIkins Co. 19. VADALA, A. J. Mycotic infections of bronchopulmonary tract. Ann. Otol., Rbin. ti Laryng. 49: q-358, 1940. 20. VAN ORDSTRAND, H. S. Primary aspergillosis. Cleveland Clin. Quart., 7: 66-73, 1940. 21. VIRCHOW, R. Beitrage zur Lehre von den beim Menschen vorkemmenden pflanzlichen Parasiten. Vircbows Arch. j. path. Anat., 9: 557-593, 1856.