Invasive pulmonary aspergillosis occurs predominantly in individuals who are neutropenic or who have severe defects in cell-mediated immunity. The isolation of Aspergillus from respiratory secretions of normal hosts usually signifies tracheobronchial colonization, not disease. Recent experience with three nonimmunocompromised patients who had invasive pulmonary aspergillosis, each of whom had Aspergillus isolated from respiratory secretions early in his illness, led to a reassessment of the significance of the isolation of Aspergillus from tracheobronchial secretions. Two of 10 nonimmunocompromised, nonleukopenic individuals who had pulmonary infiltrates and whose sputum yielded Aspergillus had invasive pulmonary aspergillosis, whereas two of five individuals who had pulmonary infiltrates and whose bronchial washings grew Aspergillus had invasive disease. These findings indicate that invasive pulmonary aspergillosis should be considered when Aspergillus is isolated from the respiratory secretions of anyone who has pneumonia, regardless of host defense status.

Invasive Pulmonary Aspergillosis in Nonimmunocompromised, Nonneutropenic Hosts

Af is an important pathogen of the bronchopulmonary system, and the clinical spectrum encompasses aspergilloma, CNPA, IPA, ABPA, bronchial asthma, and allergic alveolitis. Bronchial carriage may, however, not always be associated with pathological effects. The polymorphism of the aspergillus-related disorders seems mostly to depend upon the different responses of the hosts. This review considers the antigenic composition of Af and specific antibody responses in man in relation to the pathogenesis and diagnosis of the various forms of pulmonary aspergillosis. More than 200 macromolecular components have been listed for Af and more than 30 antigens found to react with human sera. Serum antibodies to Af are common in healthy subjects. Schonheyder and his associates (A-L) have shown that IgG, IgA and IgM antibodies in healthy subjects are directed towards antigens to which also patients with aspergillosis strongly react. With immunofluorescent staining these antigens were found to be associated with hyphal walls, and a MW 470,000 fraction from ruptured mycelium was most reactive in ELISA. The respiratory tract appears to be the major route for exposure since the humoral responses include IgA class antibodies, and sIgA antibodies are found in bronchial secretions. Moreover, IgG antibody levels to the MW 470,000 fraction correlate with occupational exposure and smoking habits. In patients with cystic fibrosis high IgG antibody levels to MW 470,000 and MW 25,000-50,000 antigen fractions were associated with the carriage of Af in the sputum. An individual patient's level of IgA antibodies to the MW 470,000 fraction was inversely related to the Af carrier rate, and this was also true for IgE dependent reactivity to Af antigens. These observations indicate that IgG antibodies to some antigens mirror the extent of antigenic exposure, whereas some IgA and IgE antibodies may play a protective role against bronchial colonization with Af. IgG antibody determinations by ELISA were found to provide a higher diagnostic efficacy in pulmonary aspergillosis than IgA antibody assays. With IgG antibodies there were statistically significant differences between patients and the controls and there was little overlap of ELISA values between the groups. The fractions of MW 250,000 with catalase activity and MW 25,000-50,000 with protease activity, were most suitable for serological diagnosis. A gel immunoelectrophoretic assay proved Af catalase to be a major diagnostic antigen in patients with aspergilloma or with an apical aspergillus lung infiltrate.(ABSTRACT TRUNCATED AT 400 WORDS)

Pathogenetic and serological aspects of pulmonary aspergillosis.

Disseminated aspergillosis in an apparently healthy patient.

A previously healthy 28-year-old man presented a few hours after inhalation of vegetal dust with acute bilateral community-acquired pneumonia, which caused death in 10 days despite treatment with broad-spectrum antibiotics, intravenous amphotericin B, inotropic support, and mechanical ventilation. A postmortem lung biopsy indicated miliary granulomatous pulmonary aspergillosis. Six similar previously published cases of acute granulomatous pulmonary aspergillosis are reviewed. This entity in adulthood may reveal a defect in neutrophil or macrophage function, such as late-onset chronic granulomatous disease.

Fatal Acute Granulomatous Pulmonary Aspergillosis in a Healthy Subject After Inhalation of Vegetal Dust

Objectives Fungal pneumonia in the immune competent host is a rarity with few reported cases in the literature. We present a series of 7 cases of recurrent fungal pneumonia in association with allergic fungal rhinosinusitis and gastroesophageal reflux disease (GERD). We hypothesised that recurrent infection may have been transported from the infected paranasal sinuses into the lung by GERD as the process was terminated by surgical fundoplication in 2 of these patients. Methods Patients were recruited into the study if they were immune competent and had recurrent fungal pneumonia and GERD. Allergic fungal rhinosinusitis was proven by biopsy. GERD was investigated by a scintigraphic test that assessed local oesophageal disease, lung aspiration and head and neck involvement with a hybrid gamma camera and X-ray computed tomography. Results All patients were shown to have GERD with 5/7 showing paranasal sinus contamination and 7/7 showing laryngopharyngeal involvement and 6/7 lung aspiration. One patient had characteristics strongly predictive of aspiration. Fundoplication led to cessation of fungal lung infection in two patients. Conclusion Recurrent fungal pneumonia in the immune competent host should raise the possibility of re-infection from the paranasal sinuses, especially in patients with GERD.

Fungal Pneumonia in The Immunocompetent Host: A Possible Statistical Connection Between Allergic Fungal Sinusitis with Polyposis and Recurrent Pulmonary Infection Detected by Gastroesophageal Reflux Disease Scintigraphy

A young woman presented with widespread bilateral infiltrates on chest X-ray and a high fever. Investigations for bacterial, mycobacterial, and fungal infections were negative. A biopsy of the lung showed granulomas, and corticosteroid medication was given on vital indication because of the rapidly progressive disease. There was a dramatic response, with regression of the chest X-ray changes and the fever and the patient was discharged on her own request with a tentative diagnosis of acute sarcoidosis. One month later she was admitted in an alarming state with almost completely consolidated lungs and died a few hours later. Autopsy revealed generalized aspergillosis. Renewed extensive investigation of the earlier lung biopsy revealed hyphae. After her death, the case history of an elder brother was traced and revealed that he had died at early age in a generalized granulomatous disease. Although no definite diagnosis can be made, it seems likely that both siblings suffered from a defect in the immune syst...

Disseminated pulmonary aspergillosis in a previously healthy young woman.

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Disseminated pulmonary aspergillosis in a previously healthy young woman.