Aspergilosis pulmonar asociada a COVID-19 en pacientes críticos: experiencia de un hospital público chileno / COVID-19-associated pulmonary aspergillosis in critically ill patients: experience of a Chilean public hospital

INTRODUCCIÓN: Se han descrito coinfecciones fúngicas por Aspergillus spp. en pacientes críticos cursando una infección por COVID-19. OBJETIVOS: Describir las características clínicas, diagnóstico, tratamiento y evolución de pacientes con síndrome de distrés respiratorio agudo con COVID-19, que cursan con aspergilosis pulmonar asociada a COVID-19 (CAPA por sus siglas en inglés) en un centro hospitalario público. Pacientes y MÉTODOS: Revisión de registros clínicos durante 12 meses en pacientes con diagnóstico de CAPA mediante cultivos de muestras respiratorias o determinación de galactomanano (GM). RESULTADOS: En 11 pacientes se diagnosticó CAPA probable (score APACHE II promedio de 11,7). Las muestras respiratorias se obtuvieron en 73% de los casos por lavado broncoalveolar y en 27% por aspirado endotraqueal. Se aisló A. fumigatus en 4 cultivos, A. niger, A. terreus y Aspergillus spp en una ocasión cada uno y los cultivos fueron negativos en 4 muestras. En 7 pacientes se realizó GM de muestras respiratorias, mediana: 3,6 (RIC: 1,71 - 4,4), en 10 pacientes se realizó GM sérica, mediana: 0,5 (RIC: 0,265 - 0,975) con 50% de ellas > 0,5. Dos pacientes mostraron hallazgos sugerentes de CAPA en la tomografía computada. Todos recibieron terapia anti-fúngica con voriconazol, con una duración promedio 14 días. Cuatro pacientes fallecieron. CONCLUSIONES: La presencia de CAPA debe ser un diagnóstico a considerar en pacientes críticos con COVID-19.

BACKGROUND: Aspergillus spp. fungal coinfections have been described in critically ill COVID-19 patients. AIM: To describe the clinical characteristics, diagnosis, treatment and evolution of patients with acute respiratory distress syndrome with COVID-19, who present with COVID-19 associated pulmonary aspergillosis (CAPA) in a single public hospital. METHODS: Retrospective review of clinical records during 12 months in patients diagnosed with CAPA by cultures of respiratory samples or determination of galactomannan (GM). RESULTS: Probable CAPA was diagnosed in 11 patients (average APACHE II score of 11.7). Respiratory samples were obtained in 73% of cases by bronchoalveolar lavage and in 27% by tracheal aspirate. A. fumigatus was isolated in 4 cultures, A. niger, A. terreus and Aspergillus spp on one occasion each and the cultures were negative in 4 samples. Respiratory sample GM was performed in 7 patients, median: 3.6 (IQR: 1.71 - 4.4). In 10 patients, serum GM was performed, median: 0.5 (IQR: 0.265 - 0.9 75) with 50% of them > 0.5. Two patients showed classic findings suggestive of CAPA on computed tomography. All received antifungal therapy with voriconazole, mean time 14 days. Four patients died. CONCLUSIONS: The presence of CAPA should be a diagnosis to be considered in critically ill COVID-19 patients.

Enfermedad granulomatosa crónica: infecciones múltiples como forma de presentación. Caso clínico pediátrico / Chronic granulomatous disease: multiple infections as clinical presentation. Pediatric case report

La enfermedad granulomatosa crónica es una inmunodeficiencia primaria infrecuente, debida a un defecto en la actividad microbicida de los fagocitos, originada por mutaciones en los genes que codifican alguna de las subunidades del complejo enzimático nicotinamida adenina dinucleótido fosfato oxidasa. La incidencia estimada es 1 en 250 000 recién nacidos vivos. Puede presentarse desde la infancia hasta la adultez, por lo general, en menores de 2 años. Las infecciones bacterianas y fúngicas, en conjunto con las lesiones granulomatosas, son las manifestaciones más habituales de la enfermedad. Los microorganismos aislados más frecuentemente son Aspergillus spp., Staphylococcus aureus, Serratia marcescens, Nocardia spp. Se reporta el caso clínico de un varón de 1 año de vida en el que se diagnosticó enfermedad granulomatosa crónica a partir de infecciones múltiples que ocurrieron simultáneamente: aspergilosis pulmonar invasiva, osteomielitis por Serratia marcescens y granuloma cervical por Enterobacter cloacae.

Chronic granulomatous disease is an uncommon primary immunodeficiency due to a defect of the killing activity of phagocytes, caused by mutations in any of the genes encoding subunits of the superoxide-generating phagocyte NADPH oxidase system. The incidence is 1 in 250 000 live births. It can occur from infancy to adulthood, usually in children under 2 years. Bacterial and fungal infections in association with granuloma lesions are the most common manifestations of the disease. Aspergillus species, Staphylococcus aureus, Serratia marcescens, Nocardia species are the most common microorganisms isolated. We describe here a case of a 1-year-old boy with chronic granulomatous disease and invasive pulmonary aspergillosis, Serratia marcescens osteomyelitis and Enterobacter cloacae cervical granuloma.

Coexistencia de Aspergilosis e Hidatidosis Pulmonar. Reporte de un caso / Coexistence of Pulmonary Aspergillosis and Hydatidosis. Case report

RESUMEN La hidatidosis es una zoonosis causada por el parásito Echinococcus granulosus. Perú es una zona endémica para esta infección, presentamos el caso de una mujer de 33 años, procedente de la región de Ica; que durante la gestación se le diagnosticó hidatidosis hepática y pulmonar y posterior al término de la gestación fue referida con tubo de drenaje torácico, disnea y dolor torácico en hemitórax derecho, de curso progresivo e imagen tomográfica de tórax que mostró quiste pulmonar basal posterior derecho. Los exámenes serológicos fueron positivos, la paciente fue sometida a resección quirúrgica con resultado histopatológico de quiste hidatídico pulmonar complicado no viable y estructura micótica consistente con aspergiloma. La coexistencia de estas dos entidades es rara y pueden ser amenazas potenciales para los pacientes. El diagnóstico y tratamiento tempranos son vitales para prevenir posibles complicaciones como la hemoptisis masiva o incluso enfermedad invasiva.

ABSTRACT Hydatidosis is a zoonosis caused by the parasite Echinococcus granulosus and Peru is an endemic zone for this infection. We present the case of a 33-year old woman from the region of Ica who, during gestation, was diagnosed with liver and pulmonary hydatidosis. After gestation was terminated, she was referred with thoracic drainage tube, dyspnea, and thoracic pain in right hemithorax, with progressive course and tomographic image of thorax showing right posterior basal pulmonary cyst. The serological analysis was positive, the patient underwent surgical resection with histopathologic result as complex non-viable pulmonary hydatidic cyst and mycotic structure consistent with aspergilloma. The coexistence of these two diseases is rare and can mean potential threats for patients. The early diagnosis and treatment are vital to prevent possible complications such as massive hemoptysis or even invasive disease.

Aspergillosis pulmonar / Pulmonary aspergillosis

RESUMEN Se presenta a una paciente de 50 años de edad, atendida durante 2 años por Consulta de Neumología, en la ciudad de Matanzas. Presentaba bronquitis crónica con tratamiento para la misma, hace 3 meses ingresa por Servicio de Medicina Interna por una neumonía de lenta resolución, asociada un síndrome general. Durante el ingreso se manejan varias posibilidades diagnósticas como: posible tuberculosis pulmonar, neoplasia de pulmón o neumonía a gérmenes atípicos. Se confirmó diagnóstico de aspergilosis pulmonar mediante lavado bronquial por broncoscopio. Se aplicó tratamiento con antifúngicos sistémicos y se logró mejoría clínica y radiológica. En esta paciente no existían evidencias de inmunosupresión (AU).

ABSTRACT We present a female patient aged 50 years, attended for two years in the Pulmonology consultation, in the city of Matanzas. She suffered chronic bronchitis with treatment; three months ago she was admitted in the Internal Medicine Service due to a low resolution pneumonia associated to a general syndrome. During her staying in the hospital several diagnostic possibilities were managed: possible pulmonary tuberculosis, lung neoplasia or pneumonia to atypical germs. The diagnosis of pulmonary aspergillosis was confirmed through bronchial lavage `per bronchoscope. no existían evidencias de inmunosupresión. The pronosis is Lung Aspergilosis due to a bronchial washing for bronchoscopy and the treatment begins with systemic antifúngicos, achieving clinical and radiological improvement. There is no evidence of inmunosupression in the patient (AU).

Aspergilose pulmonar necrotizante e aspergiloma pulmonar / Necrotizing pulmonary aspergillosis and pulmonary aspergilloma

A aspergilose pulmonar necrotizante ou semi-invasiva é um processo infecioso indolente, com consequente destruição do parênquima pulmonar, causado pela inalação de Aspergillus, geralmente Aspergillus fumigatus. O aspergiloma é caracterizado pelo desenvolvimento de uma bola fúngica numa cavidade pulmonar preexistente e pode ser visto em cerca de 50% dos doentes com aspergilose pulmonar necrotizante. Os autores apresentam um caso clínico de aspergilose pulmonar necrotizante e aspergiloma que, por sua gravidade clínica e coexistência de patologia pulmonar prévia grave, sem imunossupressão conhecida, ilustra as particularidades destas patologias.

Necrotizing pulmonary aspergillosis also called semi-invasive aspergillosis is an indolent, infectious and destructive process of the lung due to invasion by Aspergillus species, usually Aspergillus fumigatus. Aspergilloma (fungus ball) usually develops in a preexisting cavity in the lung and may be seen in nearly 50% of patients with Necrotizing pulmonary aspergillosis. The authors present a case report of necrotizing pulmonary aspergillosis and an aspergilloma with underlying chronic lung disease but without any known immunodeficiency, that illustrates the particularities of these diseases.

Colonização intracavitária pulmonar por Aspergillus: análise de 190 casos / Pulmonary intracavitary colonization by Aspergillus: analysis of 190 cases

A colonização intracavitária pulmonar aspergilar (CIPA) é caracterizada pela presença de massa miceliana de crescimento endocavitário. O agente mais frequente é o Aspergillus fumigatus, e a lesão cavitária é geralmente sequela de tuberculose e curada com história de hemoptise de repetição e baciloscopia negativa. Os autores analisaram retrospectivamente 190 casos de CIPA, entre abril de 1978 e março de 2008, no Serviço de Arquivo Médico do Hospital Universitário Lauro Wanderley e no Complexo Hospitalar Clementino Fraga, enfatizando a incidência, forma de apresentação clínica, enfermidades associadas, métodos, diagnósticos e conduta terapêutica.

The colonized intrapulmonary aspergilloma (CIPA) is characterized by the mass fungal in a existing pulmonary cavity, where the most commonly agent is the Aspergillus fumigatus. The pulmonary cavity is often result cured pulmonary tuberculosis with hemoptisis repletion history and bacilloscopy negative. The authors analyzed retrospectively 190 cases of CIPA from April 1978 to March 2008 in the University Hospital Lauro Wanderley and Hospital Complex Clementino Fraga emphasizing the incidence, clinical evolution, illness association, diagnosis method and treatment.

Pulmonary Toxocariasis Mimicking Invasive Aspergillosis in a Patient with Ulcerative Colitis

A 45-year-old-male who had underlying ulcerative colitis and presented with fever and dry cough. Initially, the patient was considered to have invasive aspergillosis due to a positive galactomannan assay. He was treated with amphotericin B followed by voriconazole. Nevertheless, the patient deteriorated clinically and radiographically. The lung biopsy revealed eosinophilic pneumonia, and ELISA for Toxocara antigen was positive, leading to a diagnosis of pulmonary toxocariasis. After a 10-day treatment course with albendazole and adjunctive steroids, the patient recovered completely without any sequelae. Pulmonary toxocariasis may be considered in patients with subacute or chronic pneumonia unresponsive to antibiotic agents, particularly in cases with eosinophilia.

Co-existence of HIV, active tuberculosis and aspergilloma in a single individual - A case report.

Summary: Tuberculosis (TB) is a disease as old as mankind, whereas in India the first case of Human Immunodeficiency Virus (HIV) was reported in 1986. HIV and TB are so closely connected that their relationship is often described as a coepidemic. Aspergilloma (Fungal Ball, Mycetoma) represents a saprophytic growth of aspergillus that colonizes in the preformed cavities commonly due to pulmonary tuberculosis (PTB). We report a case of HIV, active pulmonary tuberculosis and aspergilloma occurring in the same patient. Despite our best efforts, we could not lay our hands on any similar case in the medical literature.

Mycological microscopic and culture examination of 400 bronchoalveolar lavage [BAL] samples

The frequency of invasive opportunistic mycoses has increased significantly over the past decades especially in immunocompromised patients. Invasive aspergillosis [IA] has become a major cause of morbidity and mortality among these patients. As bronchoalveolar lavage [BAL] fluid samples are generally useful specimens in the diagnosis of invasive pulmonary aspergillosis [IPA], this study was designed to evaluate the incidence of fungal elements in at-risk patients by direct microscopy and culture of BAL samples. In a 16-month period, 400 BAL samples were obtained from several groups of different patients with pulmonary and respiratory disorders and examined by using both direct microscopy and culture. Of the 400 samples, 16 [4%] were positive direct examination with branching septate hyphae and 46 [11.5%] were positive culture: 25 [54%] Aspergillus flavus, 6 [13%] A. fumigatus, 5 [10.9%] A. niger, 1 [2.2%] A. terreus, 3 [6.5%] Penicillium spp. and 6 [13%] mixed A. flavus/A. niger. A. flavus was the most common cause of Aspergillus infection or colonization. Bone marrow transplant [BMT] recipients were the most susceptible group to fungal infection and/or colonization. Among Aspergillus species, A. flavus was the most common isolate in both infections and colonization in Iran. More studies are needed to clarify the epidemiological aspect of aspergillosis in Iran

Resección quirúrgica de aspergiloma en paciente inmunosuprimido: presentación de un caso clínico / Surgical resection of aspergilloma in immunosupressed patient: a case report

Aspergillosis refers to the spectrum of disease caused by Aspergillus species. The aspergilloma is the most common and best-recognized form of pulmonary involvement due to Aspergillus; usually developing in a preformed lung cavity and the principal association is with Tuberculosis. The true incidence of aspergilloma is not known. Although frequently asymptomatic, the presence of a fungus ball due to Aspergillus may cause hemoptysis and in cases can be fatal, with a variable mortality ranging between 9 to 30 percent. Aspergilloma usually comes to clinical attention as an incidental finding, thus the diagnosis involve clinical and radiological findings confirmed by pathology. There is no consistent evidence that aspergilloma. Responds to antifungal agents, and these drugs rarely achieve the minimal inhibitory concentrations within the lung cavities. Surgical resection, despite a high morbidity, is the only proven therapy for these cases.

La aspergilosis se refiere al espectro de enfermedades ocasionadas por la especie de Aspergillus. El aspergiloma es la forma más reconocida y común de la afección pulmonar relacionada a dicha especie, generalmente se desarrolla en una cavidad pulmonar pre-existente, la principal asociación es con secuelas de tuberculosis. Se desconoce la incidencia a nivel mundial. La mayoría de los pacientes se manifiestan asintomáticos; en raras ocasiones, debutan con hemoptisis mayor, con una mortalidad variable que oscila entre el 9 a 30 por ciento. El diagnóstico se basa en los hallazgos clínicos, imagenología y confirmados por patología. El tratamiento farmacológico no ha demostrado ser de gran utilidad, en tanto que, la cirugía a pesar de una elevada morbilidad podría ser el tratamiento de elección.

Pulmonary Spergilloma : An Interesting Case.

In many cases, the diagnosis of pulmonary aspergilloma become difficult on the basis of radiological sign by chest X-ray or computed tomography (CT) scan as it can produce wide variety of radiographic changes. Often there is a diagnostic dilemma between lung malignancy and pulmonary aspergilloma. The diagnosis also can be established by sputum examination and culture. In our case, we report a 40-year old male presented with cough and hemoptysis. He was subsequently diagnosed as a case of pulmonary aspergilloma on the basis of evidence of radiological findings mainly.

Bronchoscopy and endobronchial disease in patients with human immunodeficiency virus infection.

The natural history of human immunodeficiency virus (HIV) infection has been significantly altered since the advent of antiretroviral therapy (ART). However, lung diseases are still common in these patients. This makes flexible fibreoptic bronchoscopy a valuable diagnostic tool. Knowledge of the visual appearance of various diseases would be of utmost importance to the bronchoscopist. Timely recognition of the endobronchial appearance of these diseases can narrow the differential diagnosis and potentially mitigate an avoidable delay in the diagnosis.

Aspergilose pulmonar em paciente imunocompetente e previamente sadio / Pulmonary aspergillosis in an immunocompetent and previously healthy patient

A aspergilose pulmonar compreende uma das formas de infecção por fungo do gênero Aspergillus, tendo diversos modos de apresentação clínica a depender da imunidade e comorbidades. O objetivo deste trabalho é relatar um caso de paciente, imunocompetente e previamente hígido, que desenvolveu uma forma de aspergilose pulmonar crônica e fazer uma breve revisão sobre o assunto.

Pulmonary aspergillosis includes one of the forms of fungal infection due to the genus Aspergillus, and has several modes of clinical presentation that depend on the immunity and comorbidities. The aim of this study was to report on the case of an immunocompetent and previously healthy patient who developed a form of chronic pulmonary aspergillosis, and to make a brief review on the subject.

Endobronchial Aspergilloma: Report of 10 Cases and Literature Review

PURPOSE: A retrospective investigation of the clinical and radiologic features as well as the bronchoscopic appearance was carried out in patients with endobronchial aspergilloma. MATERIALS AND METHODS: Ten patients with endobronchial aspergilloma diagnosed by bronchoscopy and histological examination were identified at the Gyeongsang University Hospital of Korea, from May 2003 to May 2009. RESULTS: The patients included 9 men and 1 woman, and the age of the patients ranged from 36 to 76 (median, 58 years). The associated diseases or conditions were: previous pulmonary tuberculosis in 7 patients, lung cancer in 2 patients, pulmonary resection in 1 patient, and foreign body of the bronchus in 1 patient. The chest radiologic finding showed fibrotic changes as a consequence of previous tuberculosis infection in 6 patients and a mass-like lesion in 2 patients. Two patients had a co-existing fungus ball, and an endobronchial lesion was suspected in only 2 patients on the CT scan. The bronchoscopic appearance was a whitish to yellow necrotic mass causing bronchial obstruction in 7 patients, foreign body with adjacent granulation tissue and whitish necrotic tissue in 1 patient, whitish necrotic tissue at an anastomosis site in 1 patient, and a protruding mass with whitish necrotic tissue in 1 patient. CONCLUSION: An endobronchial aspergilloma is a rare presentation of pulmonary aspergilosis and is usually incidentally found in immunocompetent patients with underlying lung disease. It usually appears as a necrotic mass causing bronchial obstruction on bronchoscopy and can be confirmed by biopsy.