Scientific Letter
Aspergillus fumigatus Empyema
Empiema por Aspergillus fumigatus
Lucía Ferreiroa,b,
, M. Luisa Pérez del Molinoc, Marta Sonia González-Pérezd, Luis Valdésa,b
Corresponding author
a Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
b Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, Spain
c Servicio de Microbiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
d Servicio de Hematología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
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This was a 19-year-old man who had been diagnosed 7 months previously with intermediate-risk cortical phenotype T-cell acute lymphoblastic leukemia. He received induction, consolidation and reinduction therapies, according to standard protocols, and achieved complete remission. Complications associated with the various treatments included vitamin K deficiency, hypofibrinogenemia, pancytopenia (with hemolytic anemia requiring transfusions), hyperglycemia, and hypertransaminasemia.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Thirty days after reinduction therapy, he was admitted to the hematology department for loss of vision in the right eye, odynophagia, and fever. Vital signs showed temperature 37.5<span class="elsevierStyleHsp" style=""></span>°C, blood pressure 110/60<span class="elsevierStyleHsp" style=""></span>mmHg and heart rate 100<span class="elsevierStyleHsp" style=""></span>bpm. Breathing at rest was normal, and notable findings on physical examination included pallor of the skin and mucosa, Cushingoid facies, bronchial breath sounds in the base of the left hemithorax, with crackles reaching the middle field, edema of the lower limbs, and exudative ulceration of the foreskin. Abdominal examination was normal and no peripheral lymphadenopathies were palpated.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The most relevant additional examinations included blood tests: hemoglobin 8.2<span class="elsevierStyleHsp" style=""></span>g/dl, hematocrit 24.9%, leukocytes 1×10<span class="elsevierStyleSup">3</span>/μ1 (62% neutrophils, 35% lymphocytes), platelets 24×10<span class="elsevierStyleSup">3</span>/μl, total proteins 4.5<span class="elsevierStyleHsp" style=""></span>g/dl, GOT 117<span class="elsevierStyleHsp" style=""></span>IU/l, GPT 524<span class="elsevierStyleHsp" style=""></span>IU/l, GGT 268<span class="elsevierStyleHsp" style=""></span>IU/l, alkaline phosphatase 424<span class="elsevierStyleHsp" style=""></span>IU/l, LDH 999<span class="elsevierStyleHsp" style=""></span>IU/l, triglycerides 371<span class="elsevierStyleHsp" style=""></span>mg/dl and cholesterol 320<span class="elsevierStyleHsp" style=""></span>mg/dl. Bone marrow aspirate confirmed remission. A chest computed tomography was performed, showing a pulmonary consolidation in the left base with lucent foci suggesting cavitation, bilateral multiple pulmonary micronodules measuring less than 1<span class="elsevierStyleHsp" style=""></span>cm associated with cavitation, and left pleural effusion. Abdominal ultrasonography revealed 2 hypoechogenic hepatic lesions with echogenic centers consistent with abscesses. Brain magnetic resonance imaging showed multiple cerebral and cerebellar focal lesions, with fine peripheral enhancement, central necrosis, and a perilesional halo of edema, consistent with abscesses. The ophthalmologic examination revealed severe right endophthalmitis, requiring vitrectomy. Cerebrospinal fluid and blood were positive for galactomanan antigen. After vitrectomy, the vitreous humor showed abundant septate hyphae; <span class="elsevierStyleItalic">A. fumigatus</span> was cultured. The pleural effusion was not loculated, and had a purulent appearance with pH 7.34, leukocytes 3.6×10<span class="elsevierStyleSup">3</span>/μl (69% segments, 31% lymphocytes), glucose 87<span class="elsevierStyleHsp" style=""></span>mg/dl, total proteins 3.6<span class="elsevierStyleHsp" style=""></span>g/dl, C-reactive protein 3.08<span class="elsevierStyleHsp" style=""></span>mg/dl, procalcitonin 0.3<span class="elsevierStyleHsp" style=""></span>ng/ml, LDH 894<span class="elsevierStyleHsp" style=""></span>IU/l, adenosine deaminase 8<span class="elsevierStyleHsp" style=""></span>U/l, interleukin-6 70<span class="elsevierStyleHsp" style=""></span>393<span class="elsevierStyleHsp" style=""></span>pg/ml. Fungal hyphae were observed and <span class="elsevierStyleItalic">A. fumigatus</span> was obtained on culture. A thyroid abscess was aspirated, and hyphae were observed. Enterococcus faecalis was isolated from culture of the foreskin, and trimethoprim–sulfamethoxazole sensitive Stenotrophomonas maltophilia from 2 sputum cultures, obtained 2 months after admission.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The clinical situation was interpreted as T-cell acute lymphoblastic leukemia with late post-chemotherapy bone marrow aplasia and disseminated aspergillosis (<span class="elsevierStyleItalic">A. fumigatus</span>) during the reinduction phase, with ophthalmic, cerebral, pulmonary, pleural (empyema), hepatic, and thyroid involvement with bacterial co-infections.</p><p id="par0030" class="elsevierStylePara elsevierViewall">During admission, the patient received various courses of antifungals (amphotericin, voriconazole [up to 9<span class="elsevierStyleHsp" style=""></span>mg/kg/12<span class="elsevierStyleHsp" style=""></span>h depending on blood levels, as well as 8 intravitreal doses], AmBisome<span class="elsevierStyleSup">®</span> and caspofungin), antibacterials (meropenem, vancomycin, linezolid, cotrimoxazole, levofloxacin, amikacin, and clindamycin), and dexamethasone, and a chest tube was placed (16F, 3 days then resolution). The patient progressed slowly, except for the pleural involvement, until voriconazole was administered at doses much higher than recommended in the package insert, and plasma levels within the therapeutic range were achieved. The patient was discharged after 3 months, having remained afebrile for the last month.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A diagnosis of fungal pleural empyema poses a clinical dilemma that is especially worrying in the setting of severely immunocompromised cancer patients. Our patient met the criteria for diagnosis of proven invasive fungal disease,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleItalic">A. fumigatus</span> on this occasion, and is one of the few cases in which pleural fluid has been infected by <span class="elsevierStyleItalic">Aspergillus</span> in an immunocompromised patient.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A recent study reported a high percentage (16%; 111/708) of cultures positive for fungi in pleural fluid from cancer patients. This appears to be due to a higher incidence of invasive fungal infection in cancer patients, and improved detection of fungi by microbiological techniques. <span class="elsevierStyleItalic">Aspergillus</span> spp. were, in terms of percentages, the predominant microorganism in leukemia patients (the disease presented by our patient), suggesting that the type of cancer may be one of the risk factors for developing <span class="elsevierStyleItalic">Aspergillus</span> empyema.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Voriconazole is the recommended antifungal for the treatment of invasive aspergillosis in most patients.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Although this drug achieves high concentrations in pleural fluid,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8,9</span></a> pleural empyemas caused by Aspergillosis are usually treated with a combination of various antifungals<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> due to the high mortality rate (34%–75%, depending on when it is evaluated).<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,6</span></a> Intrapleural administration has been described in isolated cases,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,10</span></a> and more studies are required to support this strategy. Treatment for all empyemas requires chest drainage, and if the patient presents life-threatening hemoptysis, lung resection surgery should be considered.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In summary, in an immunocompromised cancer patient with pleural empyema, cultures in the appropriate media should be performed to rule out fungal infection. Treatment must consist of chest drainage and the long-term administration of a combination of various antifungals, including voriconazole, since mortality in these infections is high.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ferreiro L, Pérez del Molino ML, González-Pérez MS, Valdés L. Empiema por <span class="elsevierStyleItalic">Aspergillus fumigatus</span>. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 4 | 13 |
| 2024 October | 83 | 20 | 103 |
| 2024 September | 64 | 16 | 80 |
| 2024 August | 85 | 43 | 128 |
| 2024 July | 64 | 29 | 93 |
| 2024 June | 65 | 27 | 92 |
| 2024 May | 74 | 31 | 105 |
| 2024 April | 38 | 32 | 70 |
| 2024 March | 61 | 18 | 79 |
| 2024 February | 41 | 21 | 62 |
| 2023 March | 18 | 3 | 21 |
| 2023 February | 37 | 22 | 59 |
| 2023 January | 35 | 31 | 66 |
| 2022 December | 73 | 46 | 119 |
| 2022 November | 53 | 35 | 88 |
| 2022 October | 84 | 43 | 127 |
| 2022 September | 36 | 42 | 78 |
| 2022 August | 42 | 46 | 88 |
| 2022 July | 38 | 56 | 94 |
| 2022 June | 31 | 44 | 75 |
| 2022 May | 39 | 47 | 86 |
| 2022 April | 33 | 42 | 75 |
| 2022 March | 40 | 43 | 83 |
| 2022 February | 37 | 35 | 72 |
| 2022 January | 52 | 52 | 104 |
| 2021 December | 43 | 46 | 89 |
| 2021 November | 54 | 51 | 105 |
| 2021 October | 83 | 91 | 174 |
| 2021 September | 37 | 40 | 77 |
| 2021 August | 39 | 42 | 81 |
| 2021 July | 92 | 29 | 121 |
| 2021 June | 79 | 47 | 126 |
| 2021 May | 57 | 36 | 93 |
| 2021 April | 121 | 111 | 232 |
| 2021 March | 112 | 18 | 130 |
| 2021 February | 64 | 26 | 90 |
| 2021 January | 44 | 22 | 66 |
| 2020 December | 49 | 25 | 74 |
| 2020 November | 49 | 20 | 69 |
| 2020 October | 44 | 33 | 77 |
| 2020 September | 29 | 18 | 47 |
| 2020 August | 47 | 11 | 58 |
| 2020 July | 42 | 30 | 72 |
| 2020 June | 32 | 20 | 52 |
| 2020 May | 39 | 14 | 53 |
| 2020 April | 27 | 23 | 50 |
| 2020 March | 92 | 17 | 109 |
| 2020 February | 44 | 17 | 61 |
| 2020 January | 32 | 25 | 57 |
| 2019 December | 33 | 16 | 49 |
| 2019 November | 45 | 25 | 70 |
| 2019 October | 34 | 19 | 53 |
| 2019 September | 33 | 16 | 49 |
| 2019 August | 49 | 22 | 71 |
| 2019 July | 26 | 14 | 40 |
| 2019 June | 26 | 18 | 44 |
| 2019 May | 41 | 20 | 61 |
| 2019 April | 40 | 32 | 72 |
| 2019 March | 42 | 29 | 71 |
| 2019 February | 21 | 13 | 34 |
| 2019 January | 32 | 18 | 50 |
| 2018 December | 33 | 14 | 47 |
| 2018 November | 51 | 22 | 73 |
| 2018 October | 49 | 21 | 70 |
| 2018 September | 22 | 15 | 37 |
| 2018 May | 19 | 3 | 22 |
| 2018 April | 24 | 7 | 31 |
| 2018 March | 12 | 5 | 17 |
| 2018 February | 27 | 9 | 36 |
| 2018 January | 20 | 5 | 25 |
| 2017 December | 32 | 8 | 40 |
| 2017 November | 24 | 7 | 31 |
| 2017 October | 19 | 8 | 27 |
| 2017 September | 1 | 0 | 1 |
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