Polypoid bronchial lesions due to Scedosporium apiospermum in a patient with Mycobacterium avium complex pulmonary disease

Abstract

aaScedosporium apiospermum, the asexual stage of the fungus Pseudoallescheria boydii, exists saprophytically in soil, sewage and polluted streams with a worldwide distribution. Host factors such as systemic and local impaired host defences are considered to determine whether S. apiospermum infection occurs and how invasive it will be [1]. Lung involvement caused by S. apiospermum ranges from colonization including fungus ball formation to necrotizing pneumonia. This study reports a case of polypoid bronchial lesions caused by S. apiospermum in a patient with Mycobacterium avium complex (MAC) pulmonary disease. To our knowledge, there have been no reports of such lesions due to S. apiospermum. Case reportA 69 yr old housewife was admitted to our hospital in November 1995, for further examination of abnormal shadows on chest radiographs. She had a history of tuberculous pleurisy at the age of 16 yrs. She had been suffering from rheumatoid arthritis for 20 yrs. Interstitial pneumonia due to gold used for rheumatoid arthritis occurred at the age of 53 yrs and was improved by discontinuation of the drug. She underwent surgical procedures for joint replacement of the right hip joint at the age of 61 yrs and both knee joints at the age of 66 yrs. She had taken bucillamine since she was 61 yrs old and methylprednisolone (4 mg·day -1 ) since the age of 68 yrs. She had never smoked. She did not have any history of heavy exposure to any kind of dust. Two years before admission to the hospital, chest radiographs demonstrated small nodular shadows in the right middle lung field. One month before admission, chest radiographs showed the worsening of small nodular shadows in bilateral middle lung fields and the thickening of bronchial walls. She had never complained of any respiratory symptoms, including cough and sputum.On admission, physical examinations revealed inspiratory fine crackles in the lower back. Peripheral lymph nodes were not palpable. Her fingers had severe deformities due to rheumatoid arthritis. Her blood pressure was 124/74 mmHg. Results of laboratory examinations were as follows: haematocrit, 35.4%; white cell count, 6,200· mm -2 , with 67% neutrophils, 20.4% lymphocytes, 8.3% monocytes and 3.9% eosinophils; and CD3+ cells, CD4+ cells and CD8+ cells were 88.8%, 72.4% and 14.8%, respectively. The blastogenic response to phytohaemagglutinin was normal. C-Reactive protein was 1.73 mg·dL -1 and rheumatoid factor test was positive. Serum immunoglobulin (Ig)G, IgA, IgM and IgE levels were normal. The precipitating antibodies to Aspergillus spp. and antigen of cryptococcus were negative. Candida antigen was slightly elevated. The tuberculin skin test was negative. Chest radiographs ( fig. 1) and a computed tomography (CT) scan on admission showed clusters of small nodules in the subpleural regions of both lungs, combined with bronchiectasis, especially in the right middle lobe and left lingula bronchi.Polypoid bronchial lesions due to Scedosporium apiospermum in a patient with Mycobacterium avium complex pulmonary ...

Human and animal isolates of Pseudallescheria boydii and Scedosporium species, from Melbourne, Australia, 1977–1995

“…13 The authors of a previous report concluded that polypoid bronchial lesions caused by S. apiospermum were formed in the pre-existing dilated bronchus resulting from pulmonary disease due to the M. avium complex. 29 Our record of pulmonary infection by S. apiospermum or P. boydii in four patients 12,15,17,20 who received heart, heart ⁄ lung or dual lung transplants, during the years 1992-1995, correlates with previously reported P. boydii infection in 23 recipients of solid organ transplants, where a trend towards a higher incidence of infection in patients receiving lung transplants compared with other organ transplants was noted. 30 In this report of infections caused by S. apiospermum and P. boydii obtained between 1977 and 1995, the age range of the 19 patients was 12-83 years and the mean age was 44.1 years.…”

“…Included in our findings was a mixed infection caused by S. apiospermum and Mycobacterium avium in a patient with bronchiectasis 13 . The authors of a previous report concluded that polypoid bronchial lesions caused by S. apiospermum were formed in the pre‐existing dilated bronchus resulting from pulmonary disease due to the M. avium complex 29 …”

Atypical mycobacteriosis in two patients with rheumatoid arthritis

“…Recently, it was reported that MAC occurred in elderly women without predisposing bronchopulmonary illeness. 3 This type of MAC involved mainly the bronchial regions. In general, the respiratory symptoms of MAC are quite mild in comparison to tuberculosis and M. kansasii infection.…”

“…Characteristic CT findings of bronchial type are clusters of small nodules in the subpleural regions of the lung in combination with dilated changes of the bronchi. 3 In general, atypical mycobacterial infections occur in immunocompromised hosts. RA is one of the risk factors in atypical Mycobacterium infections; this may be a result of disease-related, impaired cell-mediated immunity and antibody-producing capacity, or the reduced chemotactic responses of polymorphonuclear cells.…”

“…[3][4][5][6][7] Almost all patients received corticosteroids with or without immunosuppressive drugs. We report here two cases of RA with atypical mycobacteriosis, even though no immunosuppressive agents were used.…”