Role of early diagnosis and aggressive surgery in the management of invasive pulmonary aspergillosis in neutropenic patients

Abstract

Invasive pulmonary aspergillosis (IPA) occurs mostly in immunocompromised hosts and especially in neutropenic patients. Improved prognosis for IPA requires early diagnosis. We report our experience in the management of IPA in patients with hematological malignancies. In prolonged neutropenia (> 10 days), thoracic CT scanning seems to be the best choice for the diagnosis of IPA (with CT halo or air-crescent signs). Its systematic use allows a dramatic reduction in the time to achieve the diagnosis, if there is evidence of a halo sign. The systematic screening for the detection of Aspergillus antigenemia with an ELISA test is helpful for early diagnosis. The detection of Aspergillus antigen (with the less sensitive latex agglutination test) on bronchoalveolar lavage (BAL) fluid may also be as useful. The treatment of IPA relies on amphotericin B (or its lipid formulations) or on azole antifungal agents. Pulmonary surgical resection should be considered either as an emergency procedure (despite persistent neutropenia) to avoid massive hemoptysis, or as an elective or diagnostic procedure. This global strategy for the management of IPA is associated with a 75-80% success rate in hematological patients. Nevertheless, the control of underlying malignancy remains a major prognostic factor.

Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease

“…A significant bronchospastic component is documented in 79% of patients when reported. As described in the literature [73][74][75][76], fever is present in only 38.5% of patients (15 out of 39), contrasting with the findings in haematological patients where fever is the most common sign (87%) [74]. High-dose corticotherapy could account for the absence of fever.…”

“…However, these results were not confirmed by others [90][91][92], and some authors even reported sensitivity as low as 29.4% [93]. In a multicentre study, sensitivity and specificity were found to be 50 and 97%, respectively, and only one-third of the patients had a positive antigen response before IPA diagnosis on CT scan [74]. Another group reported that although the sensitivity was 82.5% in 40 bone marrow-transplant recipients with proven or probable IPA, the ELISA test was also positive in 31 of 169 patients without any sign of infection [94].…”

“…In one study performed in haematological patients using a latex agglutination test, sensitivity and specificity were 67% and 89%, respectively [74]. Although the ELISA antigen test on BAL fluid is feasible and reliable, the ELISA test on serum is probably more useful due to the repeatability of the method and the possibility of earlier diagnosis.…”

Prophylaxis of invasive aspergillosis with voriconazole or caspofungin during building work in patients with acute leukemia

“…The incidence of proven or probable IA in acute leukemia is around 6% but can reach 50% in situations in which there is a risk of Aspergillus propagation and dissemination, such as during building/construction work. [4][5][6][7] Mortality from IA ranges from 40-60% in such patients. 8 Early recognition of IA is an important clinical challenge.…”

Pulmonary Findings Of H1N1 Infection In Children With Malign Disease

“…Although these radiological features are characteristic, they are not diagnostic of invasive pulmonary aspergillosis (13,14,15).…”