Treatment of pulmonary aspergilloma in cystic fibrosis by percutaneous instillation of amphotericin B via indwelling catheter.

Abstract

Pulmonary aspergilloma is a rare complication of cystic fibrosis and is a contraindication to transplantation. The elimination of an aspergilloma in a 24 year old patient with cystic fibrosis by percutaneous instillation of amphotericin B is described, enabling her to be accepted on a lung transplantation programme. (Thorax 1995;50:809-810) Keywords: cystic fibrosis, aspergilloma, Aspergillus, amphotericin B.Poor pulmonary function led to referral for lung transplantation but she was thought unsuitable because of likely intraoperative contamination of the pleural space and airways by Aspergillus. We considered whether the aspergilloma might be excised before transplantation but the opinion of the thoracic surgeons was that the dangers of pleural dissemination, infection and respiratory failure would be too great. A one month course of intravenous amphotericin (1 mg/kg/day) failed to show any evidence of a change in the aspergilloma on the CT scan.Following reports of successful intracavitary treatment of aspergillomas by an indwelling catheter it was decided to attempt this method.'2 A 6-3 French polyethylene pigtail catheter (William Cook Europe, Bjaeverskov, Denmark) was inserted into the cavity using local anaesthesia and CT scan guidance (fig Ib). An initial dose of 5 mg amphotericin B was injected, gradually increasing to 50 mg/day in 20 ml 5% dextrose. Later a smaller total volume of 5 ml was found to be best. A total of 3 g was given over 60 days. Initially the instillation of this solution caused coughing which was relieved by the instillation of 2-4 ml of 1% lignocaine into the cavity before the amphotericin B. The method was taught to the

An Unusual Case of Pulmonary Invasive Aspergillosis and Aspergilloma Cured with Voriconazole in a Patient with Cystic Fibrosis

“…However, the failure of intracavitary injections of amphotericin B may be explained by insufficient intracavitary levels of the drug or by an insufficient duration of therapy. In the case report by Ryan et al [9], the successful eradication of an aspergilloma was achieved by administration of 3 g of liposomal amphotericin B over the course of 60 days, whereas only 50 mg was administered to our patient. However, our patient had mildto-moderate hemoptysis after instillation, which caused reluctance about giving further intracavitary injections.…”

“…Five cases of pulmonary aspergilloma in adults and 5 cases in pediatric/adolescent patients with cystic fibrosis have been reported [1][2][3][4]9]. The majority of patients had long-term morbidity or mortality.…”

“…However, only the capsule form of itraconazole was available in Canada at that time, and the level of absorption can vary even in healthy hosts [14]. Because reports of intracavitary injections of amphotericin B demonstrated cure rates of 50%-60% [9,15,16], this procedure was also performed for our patient. However, despite the administration of adequate therapy with intravenous amphotericin B, intracavitary administration of amphotericin B, and administration of itraconazole, therapy failed and the patient developed recurrent invasive aspergillosis and hemoptysis.…”

“…The majority of patients had long-term morbidity or mortality. One patient had a good response to percutaneous instillation of amphotericin B via an indwelling catheter and survived to undergo lung transplantation [9]. At least 2 cases were preceded by allergic bronchopulmonary aspergillosis, and several patients have had some allergic response to Aspergillus species but insufficient evidence to diagnose allergic bronchopulmonary aspergillosis [1][2][3][4].…”

The radiological spectrum of pulmonary aspergillosis

“…The prevalence of aspergillomas in post-tuberculous cavities in the UK may be as high as 10% [12]. Other common causes of the pre-formed cystic host cavity of the aspergilloma include end-stage sarcoidosis [13] or other interstitial lung disease such as pneumoconiosis, bronchiectasis [14] as in cystic fibrosis [15] and/or ABPA, lung abscess, cavitating lung neoplasm [16], pulmonary infarct [17], atypical mycobacterial infection [18], bullous emphysema, hematoma, Pneumocystis jirovecii (formerly P.carinii ) pneumonia (PCP) [19,20], lung surgery [21 Á/23] ankylosing spondylitis, and the cavitary residue of invasive fungal infection [24,25]. Unusually, aspergillomas have been described in immunocompetent patients who do not appear to have had a pre-existing dilated lung space [26,27].…”