Scientific Letter
Persistent Hemoptysis in an Elderly Patient With Pseudoallescheria boydii Mycetoma
Hemoptisis persistente en un paciente anciano con micetoma por Pseudoallescheria boydii
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"<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Persistent Hemoptysis in an Elderly Patient With <span class="elsevierStyleItalic">Pseudoallescheria boydii</span> Mycetoma" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "527" "paginaFinal" => "528" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Cristina Colmenarejo, Ana Milagro, Elena Briz, Luis Borderías" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Cristina" "apellidos" => "Colmenarejo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Ana" "apellidos" => "Milagro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Elena" "apellidos" => "Briz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:4 [ "nombre" => "Luis" "apellidos" => "Borderías" "email" => array:1 [ 0 => "lborderiasc@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sección de Microbiología, Hospital General San Jorge, Huesca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sección de Neumología, Hospital General San Jorge, Huesca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemoptisis persistente en un paciente anciano con micetoma por <span class="elsevierStyleItalic">Pseudoallescheria boydii</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 941 "Ancho" => 990 "Tamanyo" => 86301 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mass located within the cavity in the left lower lobe, which moved when the patient changed position, showing an air crescent sign.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Species belonging to the genus <span class="elsevierStyleItalic">Scedosporium/Pseudallescheria</span> are opportunistic dematiaceous fungi that cause localized and disseminated infections, are difficult to treat and are almost always associated with immunosuppression. They are, however, rarely isolated from mycetomas in patients without severe immunosuppression.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of an 84-year-old man with a history of pleural tuberculosis 50 years previously, with a biological aortic prosthesis, admitted to the hospital with an 8-h history of bloody expectoration. Physical examination showed him to be afebrile, tachypneic at 28 breaths/min, blood pressure 130/80<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate 80<span class="elsevierStyleHsp" style=""></span>bpm, 95% oxygen saturation breathing room air, and crackles and rales in both bases on auscultation, with no other findings of interest. Clinical laboratory tests showed hematocrit 37%, and no other notable changes on complete blood count or serum biochemistry, including immunoglobulins. Chest radiograph revealed left basal infiltrate, sternal wires, and a biological aortic prosthesis. A chest computed tomography showed a cavity in the left lower lobe occupied by a solid mass consistent with mycetoma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Bronchoscopy performed after admission revealed inflammation of the mucosa in the left basal segments, with no neoplastic findings on histology. A Gram stain of the bronchial aspirate showed filamentous elements suggestive of fungi, and after 9 days of culture in appropriate medium for filamentous fungi, <span class="elsevierStyleItalic">Scedosporium apiospermum/Pseudallescheria boydii</span> was isolated from the sputum and bronchial aspirate.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Arterial embolization was performed and treatment was started with voriconazole, but hemoptysis persisted, so a lower left lobectomy was performed. The surgical piece revealed a cystic cavity measuring 3<span class="elsevierStyleHsp" style=""></span>cm×2<span class="elsevierStyleHsp" style=""></span>cm×2<span class="elsevierStyleHsp" style=""></span>cm. Hyphae were visualized on fluorescence microscopy using calcofluor-white. <span class="elsevierStyleItalic">S. apiospermum/P. boydii</span> were identified from the culture. Results of the amplification and sequencing of ITS regions were consistent with <span class="elsevierStyleItalic">P. boydii</span>. The patient has remained asymptomatic since the intervention and there has been no recurrence of hemoptysis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The genus <span class="elsevierStyleItalic">Scedosporium/Pseudallescheria</span> is composed of filamentous fungi belonging to the <span class="elsevierStyleItalic">Microascaceae</span> family. These are pleomorphic, dematiaceous fungi, with both sexual and asexual reproduction.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Six species have been identified to date using molecular phylogeny techniques: <span class="elsevierStyleItalic">Scedosporium prolificans</span>, <span class="elsevierStyleItalic">S. apiospermum</span>, <span class="elsevierStyleItalic">P. boydii</span>, <span class="elsevierStyleItalic">Scedosporium aurantiacum</span>, <span class="elsevierStyleItalic">Pseudallescheria minutispora</span> and <span class="elsevierStyleItalic">Scedosporium dehoogii</span>, the last 5 constituting the <span class="elsevierStyleItalic">S. apiospermum/P. boydii</span> complex. Species in which sexual reproduction has been identified are called <span class="elsevierStyleItalic">Pseudallescheria</span>.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. prolificans</span> causes infections with high mortality rates, since it is a more virulent species and resistant to practically all available antifungal agents. It is found all over the world, but fewer <span class="elsevierStyleItalic">S. prolificans</span> infections are reported in the north of Spain, Australia and the United States.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5–7</span></a> It is not part of the human microbiota, and is acquired spontaneously from exogenous sources. It has been isolated from soil samples, stagnant water, streams, and from contaminated environments in general.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> The most common routes of entry are the inhalation and aspiration of conidia. Both the <span class="elsevierStyleItalic">S. apiospermum/P. boydii</span> complex and <span class="elsevierStyleItalic">S. prolificans</span> are important emerging opportunistic pathogens that have been related with a growing number of cases of infection and can colonize surfaces, ducts or cavities.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A study conducted in patients admitted to 29 Spanish hospitals concluded that the prevalence of colonization or infection by filamentous fungi was 1.6 per million inhabitants, and that the second most common fungus after <span class="elsevierStyleItalic">Aspergillus</span> spp. is <span class="elsevierStyleItalic">Scedosporium</span> spp.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Depending on the patient's immune status, this pathogen, like <span class="elsevierStyleItalic">Aspergillus</span> spp., can colonize the respiratory system, causing bronchiectasis and cavities with formation of mycetomas, or severe forms of disseminated invasive disease.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The case we describe involved a non-invasive infection-colonization of an existing cavity, possibly caused by tuberculosis. This clinical form has been called mycetoma or pseudallescherioma by different authors,<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8,9</span></a> and several studies have been published on <span class="elsevierStyleItalic">Scedosporium</span> mycetoma in patients with immune deficiency due to HIV, insulin-dependent diabetes, cancer, solid organ transplants and/or immunosuppressive treatments or corticosteroids. More exceptional cases have been reported in immunocompetent patients with an accumulation of predisposing factors, such as bronchiectasis or tuberculosis. This was the case in our patient, who, despite his advanced age, presented no other evidence of severe immune deficiency.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In addition to the inflammatory response with vascular proliferation observed in mycetomas, <span class="elsevierStyleItalic">Scedosporium</span> possesses proteases and peptidases that can degrade human fibrinogen and cleave the fibronectin and laminin of the basement membrane of the lung tissue, favoring vascular invasion, dissemination and the development of hemoptysis, which can be persistent – as observed in our patient.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A specific diagnosis of <span class="elsevierStyleItalic">Scedosporium</span> colonization or infection cannot be determined from imaging studies, clinical examinations, and histopathological findings.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleItalic">S. apiospermum/P. boydii</span> colonies are lighter in color and more cottony in texture than <span class="elsevierStyleItalic">S. prolificans</span> in standard culture media. It is essential to identify the species, as they differ in terms of virulence and sensitivity to antifungal agents. Newly described species are practically indistinguishable in morphological terms, so they must be differentiated using molecular techniques or proteomics. The targets are sequences that encode the ribosomal RNA complex (18s, 5.8s and 28s), ITS regions, and due to their greater resolving power, genes that encode proteins such as calmodulin or β-tubulin.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Mycetomas must be treated with a combination of surgery and antifungal treatment when possible. <span class="elsevierStyleItalic">S. apiospermum/P. boydii</span> responds better to voriconazole, caspofungin, micafungin and anidulafungin. <span class="elsevierStyleItalic">S. prolificans</span> is resistant to azoles and amphotericin B. Several publications have highlighted the value of the synergistic action of several anti-fungal agents whenever possible.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,15</span></a> In our patient, we decided to perform a lobectomy with resection of the mycetoma, in view of the repeated episodes of hemoptysis despite embolizations and treatment with voriconazole. The patient has remained asymptomatic without recurrence for 18 months.</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: Colmenarejo C, Milagro A, Briz E, Borderías L. Hemoptisis persistente en un paciente anciano con micetoma por <span class="elsevierStyleItalic">Pseudoallescheria boydii</span>. Arch Bronconeumol. 2017;53:527–528.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 941 "Ancho" => 990 "Tamanyo" => 86301 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mass located within the cavity in the left lower lobe, which moved when the patient changed position, showing an air crescent sign.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fungi causing eumycotic mycetoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. 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Klaassen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1439-0507.2011.02137.x" "Revista" => array:7 [ "tituloSerie" => "Mycoses" "fecha" => "2011" "volumen" => "54" "numero" => "Suppl. 3" "paginaInicial" => "12" "paginaFinal" => "21" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22126524" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "titulo" => "Acknowledgements" "texto" => "<p id="par0065" class="elsevierStylePara elsevierViewall">We thank Dr Luis Torres of the Microbiology Department of Hospital San Jorge and Dr Antonio Rezusta of the Microbiology Department of Hospital Miguel Servet for their help with the microbiological studies.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005300000009/v2_201708291344/S1579212917302173/v2_201708291344/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005300000009/v2_201708291344/S1579212917302173/v2_201708291344/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212917302173?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 2 | 6 |
| 2024 October | 47 | 20 | 67 |
| 2024 September | 52 | 22 | 74 |
| 2024 August | 80 | 41 | 121 |
| 2024 July | 52 | 22 | 74 |
| 2024 June | 74 | 22 | 96 |
| 2024 May | 80 | 26 | 106 |
| 2024 April | 40 | 31 | 71 |
| 2024 March | 57 | 19 | 76 |
| 2024 February | 44 | 20 | 64 |
| 2023 March | 11 | 5 | 16 |
| 2023 February | 53 | 28 | 81 |
| 2023 January | 36 | 28 | 64 |
| 2022 December | 56 | 35 | 91 |
| 2022 November | 55 | 20 | 75 |
| 2022 October | 73 | 48 | 121 |
| 2022 September | 32 | 26 | 58 |
| 2022 August | 37 | 49 | 86 |
| 2022 July | 42 | 44 | 86 |
| 2022 June | 33 | 43 | 76 |
| 2022 May | 35 | 31 | 66 |
| 2022 April | 35 | 39 | 74 |
| 2022 March | 38 | 35 | 73 |
| 2022 February | 34 | 33 | 67 |
| 2022 January | 37 | 49 | 86 |
| 2021 December | 33 | 37 | 70 |
| 2021 November | 36 | 47 | 83 |
| 2021 October | 46 | 46 | 92 |
| 2021 September | 30 | 45 | 75 |
| 2021 August | 27 | 42 | 69 |
| 2021 July | 21 | 31 | 52 |
| 2021 June | 34 | 39 | 73 |
| 2021 May | 34 | 57 | 91 |
| 2021 April | 62 | 90 | 152 |
| 2021 March | 53 | 33 | 86 |
| 2021 February | 18 | 29 | 47 |
| 2021 January | 26 | 17 | 43 |
| 2020 December | 35 | 21 | 56 |
| 2020 November | 28 | 19 | 47 |
| 2020 October | 25 | 13 | 38 |
| 2020 September | 21 | 7 | 28 |
| 2020 August | 13 | 10 | 23 |
| 2020 July | 22 | 21 | 43 |
| 2020 June | 27 | 7 | 34 |
| 2020 May | 13 | 11 | 24 |
| 2020 April | 25 | 19 | 44 |
| 2020 March | 24 | 8 | 32 |
| 2020 February | 22 | 16 | 38 |
| 2020 January | 20 | 21 | 41 |
| 2019 December | 23 | 18 | 41 |
| 2019 November | 20 | 17 | 37 |
| 2019 October | 17 | 13 | 30 |
| 2019 September | 14 | 7 | 21 |
| 2019 August | 26 | 20 | 46 |
| 2019 July | 26 | 11 | 37 |
| 2019 June | 15 | 16 | 31 |
| 2019 May | 30 | 25 | 55 |
| 2019 April | 54 | 23 | 77 |
| 2019 March | 30 | 26 | 56 |
| 2019 February | 28 | 19 | 47 |
| 2019 January | 15 | 24 | 39 |
| 2018 December | 20 | 20 | 40 |
| 2018 November | 53 | 11 | 64 |
| 2018 October | 81 | 23 | 104 |
| 2018 September | 30 | 5 | 35 |
| 2018 May | 31 | 0 | 31 |
| 2018 April | 29 | 9 | 38 |
| 2018 March | 42 | 7 | 49 |
| 2018 February | 50 | 11 | 61 |
| 2018 January | 42 | 18 | 60 |
| 2017 December | 66 | 18 | 84 |
| 2017 November | 0 | 2 | 2 |
| 2017 September | 0 | 1 | 1 |
| 2017 July | 0 | 1 | 1 |
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