Locally invasive pulmonary aspergillosis occurring in a gardener: an occupational hazard?

Abstract

Fatal locally invasive pulmonary aspergillosis occurred in a previously fit young patient who had no predisposing factors other than exposure to fungal spores in his occupation as a gardener.Invasive pulmonary aspergillosis is uncommon, usually occurring in immunocompromised patients or in those with abnormal lungs. We describe a fatal case occurring in a previously fit young man.Case report A 34 year old man was admitted as an emergency with a five day history of dyspnoea, unproductive cough, fever, and anorexia. He had worked as a gardener for 14 years and had never left Britain. He was heterosexual and denied intravenous drug abuse. Five months previously he had had an episode of salmonella gastroenteritis, when a routine chest radiograph was normal. On examination he had central cyanosis and pyrexia (38°C). His respiratory rate was 40/min and heart rate 120/min. Chest ausculation indicated fine inspiratory crackles and bronchial breath sounds at both bases. A chest radiograph showed bilateral basal alveolar shadowing. Initial blood gas measurements when he was breathing air were: arterial oxygen tension (Pao2) 8-4 kPa, arterial carbon dioxide tension (Paco2) 4 9 kPa, pH 7-43. There was a neutrophil leucocytosis (16 x 109/l). He was treated with intravenous fluids, erythromycin 1 g four times daily, physiotherapy, and continuous 75% inspired oxygen. After 48 hours he remained febrile and gentamicin 80 mg thrice daily and co-trimoxazole 960 mg twice daily were added.After seven days the basal shadowing on his chest radiograph had become more extensive and fibreoptic bronchoscopy and bronchial biopsy were carried out. Histological examination showed extensive replacement of the bronchial wall by epithelioid granulomas showing small central foci of necrosis and surrounded by neutrophils, plasma cells, and lymphocytes. Neither fungi nor acid fast bacilli were seen. Prednisolone 40 mg/day and antituberculous treatment (rifampicin, isoniazid, ethambutol, and pyrazinamide) were started. The Mantoux test and blood and sputum cultures gave negative results. Paired titres of antibodies to Mycoplasma pneumoniae, Legionella pneumophila, and a range of pulmonary viral pathogens showed no appreciable rise, and screening for human immunodeficiency virus gave a negative result. On the 19th day his condition deteriorated; radiograAddress for reprint requests:

Eosinophilic pneumonia as a presentation of occult chronic granulomatous disease

“…The features of this patient's presentation and her course are similar to other cases in the literature in which presumed immunocompetent individuals initially present with hyper-IgE, eosinophilia (of blood, tissue, or BAL), often after massive exposure and then, either simultaneously or subsequently, develop an IPA characterized by suppurative granulomas within the parenchyma of the lung [9][10][11][12][13][14].…”

“…Finally, ZUK et al [14] reported the case of a previously healthy gardener aged 34 yrs who presented with a 5 day history of dry cough, fever, and dyspnoea. A chest radiograph revealed bilateral basal infiltrates.…”

Bioaerosol in Composting Facilities: Occupational Health Risk Assessment

“…One case was organic dust toxic syndrome (ODTS), one case was insufficiently characterized (hypersensitivity pneumonitis or ODTS), one case was external otitis from Aspergillus niger, and three were invasive aspergillosis (Bünger et al, 2007;Clark et al, 1984;Weber et al, 1993). The latter cases concerned a worker in a green-waste composting plant, a professional gardener that probably handled compost, and a welder who spread rotting tree and plant mulch from a sack around his garden (Russell et al, 2008;Vincken and Roels, 1984;Zuk et al, 1989). The three cases of invasive aspergillosis did not represent typical characteristics for individual risk factors because the patients were not known to be immuno-compromised.…”

Occupation, Lifestyle, Diet, and Invasive Fungal Infections

“…These patients were either agricultural or manual workers in ''moldy'' environments. In another report from the UK, fatal locally invasive pulmonary aspergillosis occurred in a previously healthy young patient who had no predisposing factors other than exposure to fungal spores in his occupation as a gardener [25].…”