Aspergillus laryngotracheobronchitis presenting as stridor in a patient with peripheral T cell lymphoma.

Abstract

radiograph and computed tomographic scan were normal. Aspergillus fumigatus was isolated repeatedly from the sputum from day 9 onwards, and blood cultures were negative for bacteria and fungi. Broad spectrum antibiotics and granulocyte colony-stimulating factor were administered. His fever gradually subsided and the white blood cell count increased to 7.2 x 109/l on day 24 with an absolute neutrophil count of 4.5 x 1 09/l. However, the hoarseness and productive cough persisted. The oxygen saturation of haemoglobin while breathing room air was 95%. Bronchoscopic examination, performed on day 25, disclosed the presence of creamy-white, exophytic lesions on the upper surface of both vocal cords and the supraglottic area in a symmetrical fashion ( fig 1A). Mobility of both cords was impaired. The epiglottis was normal. Beyond the vocal cords there was diffuse tracheobronchitis with erythematous and oedematous mucosa. Multiple raised cream-coloured plaques were found throughout the tracheal mucosa. A single ulcer with overlying fibrinous exudate was also noted over the right main bronchus (fig 1 B). There was no evidence of distal airway involvement. The exophytic lesions on both vocal cords were removed with the biopsy forceps as completely as possible. Both vocal cords were then found to have been partially destroyed with ulcers on their upper surface. Histologically, the tenacious plugs from both vocal cords consisted of numerous septate branching hyphae consistent with Aspergillus species, admixed with mucus and inflammatory cells. Systemic treatment with amphotericin B was introduced on day 26 at a dose of 1 mg/kg per day. The patient's cough and hoarseness improved gradually and stridor was no longer audible after two days of treatment. His voice had returned to almost normal one week later. Follow up bronchoscopy two weeks later showed that the lesions on the vocal cords and trachea had disappeared, with almost complete healing of the ulcer on the right main bronchus. Cytological examination of the bronchial washing fluid did not reveal any hyphal elements. Follow up fungal culture of the sputum was also negative. Because of severe systemic side effects amphotericin B was discontinued on day 45 at a cumulative dose of 1080 mg. Treatment was continued with oral itraconazole, 200 mg twice daily. The patient's respiratory symptoms continued to improve and the follow up chest radiographs remained clear. Unfortunately, the patient had a relapse of his lymphoma and exacerbation of the haemophagocytic syndrome. Chemotherapy was resumed under cover of strong antibiotics but the patient died on the 53rd hospital day from septic shock.

Isolated invasive Aspergillus tracheobronchitis: a clinical study of 19 cases

“…However, the coexistence of various pathological features, such as occlusion, ulceration and pseudomembranes, has often been observed in IATB patients [4,11,19,21,22,26,27,29–33]. There are also reports of some histologically diagnosed IATB patients who showed mild superficial mucosa erosion or necrosis only [4,10,11,18,25,34–36]. In 1993, Kemper et al.…”

Many faces of pulmonary aspergillosis

“…DENNING et al [66] found itraconazole to be as effective as amphotericin-B, however, its role needs to be further studied. Itraconazole is also used empirically as a prophylaxis against aspergillus in high-risk patients with neutropenia or on long-term corticosteroid therapy [67][68][69][70][71].…”

Case Report of a Child after Hematopoietic Cell Transplantation with Acute Aspergillus Tracheobronchitis as a Cause for Respiratory Failure

“…In pediatric patients with invasive aspergillosis, having undergone HCT led to a sixfold higher risk of death and the only predictor of improved survival was surgical intervention [20]. Survival of AT is possible if diagnosis is made promptly and provided the patient can tolerate removal of the infected material [5, 15, 16, 18, 21]. …”