Endobronchial Fungal Disease: An Under-Recognized Entity

Abstract

Most fungi enter the human body via inhalation; however, endobronchial fungal infection (EBFI) seems to be a rare manifestation compared to pulmonary or systemic disease. This presentation seems to be related to environmental factors as well as to the host status. With the increasing popularity of flexible bronchoscopy, it is being recognized with a higher frequency. Bronchoscopic findings in EBFI vary from mild mucosal inflammation to central airway obstruction. We searched English literature related to the topic and found 228 total cases of EBFI: Aspergillus species (121), Coccidioides immitis (38), Zygomycetes (31), Candida species (14) Cryptococcus neoformans (13), and Histoplasma capsulatum (11). We have also included a single case of endobronchial Pseudallescheria boydii infection in a lung transplant recipient that has not been reported previously. Most patients were immunocompromised, exhibited systemic manifestations of the primary infection, and responded to appropriate therapy. EBFI should be included in the differential diagnosis of any form of airway lesions in immunocompromised patients, especially among residents from the endemic areas.

Clinical and radiologic manifestations of pulmonary cryptococcosis in immunocompetent patients and their outcomes after treatment

“…Endobronchial obstruction in association with other pulmonary abnormalities, similar to our cases, have been described (14,19), and, unexpectedly, appeared to be more common in immunocompetent patients (19). However, the incidence of direct airway involvement remains unknown (19).…”

Invasive Tracheobronchial Aspergillosis in a Patient with Systemic Lupus Erythematosus-dermatomyositis Overlap Syndrome

“…How organizing pneumonia is generated in patients with Aspergillus infection unknown, but a few studies of semi-invasive pulmonary aspergillosis have found that organizing pneumonia can develop in areas without hyphae (11). As was seen in the present case, A. fumigatus infection is a leading cause of ITBA, followed by A. flavus, A. niger and A. nidulans (12). The fact that the non-segmental consolidations with ground glass opacities rapidly spread from the right basal lung area to the right middle lobe or left whole lung implies that those lesions were probably caused by SLE/DM.…”

Pulmonary Mucormycosis Presenting as Nonresolving Pneumonia in a Patient With Diabetes Mellitus

“…Diabetic individuals have increased serum iron because of impaired transferrin binding, which may contribute to their increased risk of infection. 3 Patients usually present with prolonged high-grade fever that is unresponsive to broad-spectrum antibiotics. Nonproductive cough is a common symptom, whereas hemoptysis, pleuritic chest pain, and dyspnea are less common.…”

“…The majority of EBM cases have been described in patients with diabetes mellitus. 3 Furthermore, pulmonary mucormycosis tends to present a more subacute and less fulminant course in these patients. 2 Our patient's initial presentation was similar to an acute bacterial lung infection that partially responded to antibiotic therapy, and he subsequently presented with hemoptysis, a common feature in EBM.…”

“…The majority of endobronchial fungal infections occur in association with systemic dissemination in immunocompromised hosts. 3 Herein, we report a case of isolated pulmonary mucormycosis with endobronchial involvement presenting as nonresolving pneumonia in a diabetic patient who was successfully managed with medical therapy.…”