Multiple pulmonary aspergillomas in acute leukemia

Abstract

We present here a case of acute myelomonocytic leukemia treated with arabinosyl cytosine, long‐term broad spectrum antibiotics, and other supportive measures. The patient developed bilateral multiple pulmonary fungus balls almost simultaneously with a clinical and bone marrow remission of acute leukemia. The exact pathophysiology of these mycetomas is not clear, but the data are compatible with the hypotheses that the multiple mycetomas were preceded either by multiple pulmonary emboli with subsequent necrosis and infection or by multiple pulmonary hemorrhagic infarctions due to aspergillosis with subsequent aspergilloma formation. Neither alternative has been previously reported. The patient was treated with intravenous amphotericin B and aerosolized nystatin with resolution of the pulmonary lesions. Since the patient went into complete remission of the leukemia near the time of recognition of the aspergillosis, it is difficult to define the effect of the therapy on the pulmonary lesions.

Recognition and successful management in pulmonary aspergillosis in leukemia

“…'~ The poor prognosis of invasive aspergillosis in the compromised host has been well d o c~m e n t e d .~~'~*~~ We previously postulated that this clinical syndrome might be ascribed to pulmonary infarction due to vascular occlusion by invasive aspergillus with subsequent distal cavitation and fungus ball formation. 6 The evidence for this pathophysiological mechanism includes the observation that sputum cultures were positive for aspergillosis before cavitation in three of our patients (Cases 6 , 7 and 9), that invasion of pulmonary arteries by aspergillus with distal infarction, cavitation, and fungus ball formation was demonstrated at autopsy in two patients (Cases 5 and S), and that distant concomitant hematogenous spread occurred in 2 patients (Cases 2 and 5).…”

Pulmonary Aspergillosis in Immunosuppressed Patients with Haematological Malignancies

“…In the past the prognosis of invasive pulmonary aspergillosis was extremely poor. The first reports of successful treatment appeared just over a decade ago [40,41] and now several studies have demonstrated that a significant proportion of patients can be cured if treatment is started early. A study from Baltimore [42] has shown a cure in 50 per cent of patients, with a partial response in the other 50 per cent, when treatment was started within % h of pulmonary infiltrates appearing.…”

The air crescent sign of invasive pulmonary aspergillosis in acute leukaemia.

“…The formation of air crescents in such patients appears to be rare, and to our knowledge only 12 similar cases have been reported. [2][3][4][5] The clinical course of the patients described suggests that the attainment of haematological remission may have been more relevant to their recovery than antifungal treatment.…”

“…This clinical and pathological picture clearly contrasts with the rapid development of air crescents and the histological findings noted in our own patients and in the similar cases previously described. [2][3][4][5] Invasive pulmonary aspergillosis in patients with acute leukaemia is often difficult to diagnose, and usually requires lung biopsy, either transbronchially using the fibreoptic bronchoscope or as an open procedure. In all 12 previously described patients with acute leukaemia who developed air crescents and in the four patients described here AspergiUlus species were the only causative organisms identified.…”