Successful management of postpneumonectomy Aspergillus pleural empyema by combined surgical and anti-fungal treatment with voriconazole and caspofungin

Abstract

Aspergillus pleural empyema is a rare but often fatal infection complicating thoracic surgery. Three men and one woman aged 23-47 years were diagnosed with Aspergillus pleural empyema after lung resection. Underlying diseases were lung cancer (n = 2), Hodgkin's disease (n = 1) and thoracic trauma (n = 1). The treatment protocol consisted of systemic anti-fungal treatment with caspofungin and voriconazole, intrapleural application of amphotericin B and surgical debridement with secondary closure of the leaking bronchial stump. Two patients with chronic Aspergillus pleural empyema had been pretreated with itraconazole and/or amphotericin B. Two patients were treated with a thoracostoma. Two patients had undergone pneumonectomy for previously diagnosed pulmonary aspergillosis. Caspofungin was given for 13-60 days, Voriconazole for up to 100 days. Surgical debridement was performed in all cases and in two cases the created thoracostoma was closed during a second surgical procedure. Aspergillus PCR using blood samples, bronchoalveolar lavage or aspiration fluid was used for monitoring. All four patients had complete clinical and microbiological remission. Our case series shows promising results and underscores the importance of a combined therapeutic approach for Aspergillus pleural empyema consisting of anti-fungal treatment and surgery. Voriconazole and caspofungin seem to be a suitable combination for this infection.

Aspergillus PCR-Based Investigation of Fresh Tissue and Effusion Samples in Patients with Suspected Invasive Aspergillosis Enhances Diagnostic Capabilities

“…Paradoxically, although PE seems to be this frequent, data on biomarkers in PE are rare. In a recent report, Bonatti et al found positive Aspergillus PCR signals in pleural fluid samples from four patients with culturally proven Aspergillus empyema (22). These findings suggest that analyzing pleural fluid for biomarkers such as Aspergillus PCR results might be useful, as has been seen for cerebrospinal fluid (12,32); however, our data show a lower sensitivity for effusion samples than for tissue samples, representing a possible sample error as a dilution effect might by present.…”

“…Bonatti et al recently reported on Aspergillus-specific PCR in pleural effusion samples from 4 patients with Aspergillus pleural empyema, and they observed PCR positivity in the majority of samples (22). Based on the high sensitivity of PCR and the typical subpleural localization of nodular infiltrates in IA, analysis of pleural fluid samples with Aspergillusspecific PCR might be a promising tool, as pleural fluid specimens can be obtained safely for the majority of hematological patients, even those not deemed eligible for invasive procedures (23).…”

Isolated secondary fungal infections of pleural cavity

“…Aspergillus ampiyemlerine literatürde genel olarak tekli vaka bildirimleri olarak rastlanmaktadır [11][12][13][14]. En geniş seri Kearon ve ark.…”

“…Çok çeşitli şekillerde karşımıza çıkabilir, genellikle üst lob infiltrasyonu olan plevral efüzyon, kavite veya miçetoma izlenir. Tekrarlayan pnömotoraks şeklinde ortaya çıkan bir vaka da bildirilmiştir [14]. Bilgisayarlı tomografi ve akciğer grafilerinde akciğer parankim tutulumu izlenmez [12].…”

Successful Treatment of <i>Aspergillus</i> Empyema Using Open Window Thoracostomy Salvage Treatment and the Local Administration of an Antifungal Agent

“…The types of pulmonary aspergillosis are classified as aspergilloma, invasive pulmonary aspergillosis, chronic pulmonary aspergillosis (CPA), and allergic bronchopulmonary aspergillosis; however, aspergillus empyema is rare (3). Empyema that is complicated with pneumonectomy occurs in 2-16% of cases (4); in general, the common causative pathogens are staphylococci, streptococci, and gram-negative rods (5). Candida spp.…”