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A 70-year-old male had a cavity in his lungs and repeated chest infections for 6 months.
.
.
Male with a medical history, 70 years old, smoked 54 years, is a retired office worker
.
Repeated chest infection for 6 months
.
At first, he coughed with sputum, but later it was dry cough
.
The patient complained: exertional dyspnea, general fatigue, decreased appetite, and weight loss of about 5 kg within six months
.
No hemoptysis, night sweats or fever
.
The patient has ischemic heart disease, coronary artery bypass graft surgery 12 years ago, chronic obstructive airway disease, hypertension and hypercholesterolemia
.
When the patient was 2 years old, his mother died of tuberculosis
.
Therapies include inhaled corticosteroids, long-acting inhaled anticholinergic drugs, low-dose aspirin, ACE inhibitors and statins
.
On physical examination, the pulse rate was 70 bpm and normal
.
No heat, the oxygen saturation in indoor air is 97%
.
Clubbing appeared very early
.
Cardiovascular examination revealed a systolic murmur
.
Respiratory examination showed that the bilateral air intake was reduced, but there was no popping or wheezing
.
Abdominal examination is normal
.
Laboratory examination ➤ Except for eosinophils of 0.
6×109/L (0.
0-0.
4×109/L), the complete blood count is normal .
➤ Erythrocyte sedimentation rate (ESR) is 88 mm/h (1-22 mm/h), and C-reactive protein (CRP) is 60 mg/L (0-10 mg/L)
.
➤ Urea nitrogen, creatinine, electrolytes and liver function tests are normal
.
Based on chest X-ray (Figure 1) and computed tomography (CT) (Figures 2 and 3), further laboratory tests and bronchoscopy were performed: ➤ Serum IgE 2378 ng/ml➤ Aspergillus fumigatus (m3) ) Antibody 12.
1 ng/ml (positive) ➤ Anti-Aspergillus IgG 149 ng/ml (positive) ➤ Antinuclear antibody (negative) ➤ Anti-neutrophil cytoplasmic antibody (negative) ➤ Galactomannan 0.
2 ng/ml ( Positive >0.
5 ng/ml) ➤ Ziel-Nielson staining of acid-fast bacilli negative ➤ Bronchoscopy showed no evidence of intrabronchial lesions ➤ Bronchoalveolar lavage showed Gram-positive cocci and Gram-negative bacilli ➤ Bronchoscopy: No malignant cells, no non-specific inflammatory changes.
Figure 1 PA chest radiograph showing a cavity in the left lung apex
.
Figure 2 CT scan in the supine position
.
Figure 3 CT scan in prone position
.
Combining the above tests, what is the most likely diagnosis? A.
Aspergillus B.
Tuberculosis C.
Malignant tumor D.
Sarcoidosis E.
Klebsiella pneumonia Correct answer: Aspergillus Aspergillus is widely distributed and in nature, it exists in organic matter necrosis, moldy grains, feed, water, soil, In clothes and furniture
.
It is often infected by inhaling spores in the air
.
It grows best at 37°C.
Microspores with a diameter of 2 to 3 µm are easily inhaled and deposited deep in the lungs
.
May cause a variety of clinical symptoms, although the most obvious lung disease
.
The most common cause of lung Aspergillus infection is Aspergillus fumigatus, and a few are Aspergillus flavus
.
Aspergillus is a conditional pathogen.
Inhalation of patients with underlying lung diseases or weakened immune function can cause a variety of diseases
.
Aspergillus grows first in the cavities of the lungs, and the presence of cavities in the lungs is the most common predisposing factor
.
In most cases, the lesion remains stable
.
About 10% of Aspergillus will be relieved or disappear spontaneously without treatment
.
Rarely, the aspergillus ball enlarges
.
Most patients are asymptomatic, sometimes as long as several years, and only accidentally discovered
.
The patient may have hemoptysis, sometimes severe
.
It may manifest as chronic cough or difficulty breathing
.
In radiology, the aspergillus balls are obvious in the upper lobe, the masses in the cavity are active, and there are air crescent signs around them
.
The position of the aspergillus ball changes with the change of the patient's position
.
Sputum culture may show the presence of Aspergillus, but culture is negative in 50% of cases
.
In almost all cases, serum IgG antibodies of Aspergillus are positive; however, false negatives may occur in non-Aspergillus fumigatus patients or patients receiving corticosteroid therapy
.
For asymptomatic patients, no treatment is required
.
There is no consistent evidence that Aspergillus responds to antifungal drugs such as amphotericin B or voriconazole
.
Intracavitary or bronchial antifungal drugs can be used, but this is usually suitable for patients with severe hemoptysis
.
Surgical treatment of Aspergillus is related to a relatively high fatality rate, which ranges from 7% to 23%
.
There are also considerable morbidities after surgery, such as bleeding, pleural disease, bronchopleural fistula, empyema and respiratory failure
.
Further testing: The patient then had shortness of breath and developed a cough and green sputum
.
No fever, there was a crackling sound in the upper left lobe on respiratory examination
.
1.
Laboratory testing ➤ White blood cell count 12.
5x109/L (4-11 x109/L) ➤ Neutrophils 9.
3x109/L (2.
0-7.
5 x109/L) ➤ Eosinophils 0.
2 x109/L (0.
0-0.
4 x109/L) 2.
Arterial blood gas analysis in indoor air ➤ PO2: 10.
61 kPa (79.
8 mm Hg) ➤ PCO2: 3.
86 kPa (29 mm Hg) ➤ pH: 7.
49 ➤ HCO3: 23.
7 mmol/L 3.
Lung function test ➤ FEV1 56% predicted value ➤ FVC 80% predicted value ➤ FEV1/FVC 53% ➤ TLC 84% predicted value ➤ RV 98% predicted value ➤ DLco 33% predicted value combined with the above, what is the most likely diagnosis? A.
Aspergillus with bacterial infection B.
Malignant tumor C.
Chronic necrotizing aspergillosis D.
Invasive pulmonary aspergillus E.
A and C Correct answer: E Chronic necrotizing aspergillosis (CNA) is caused by the invasion of Aspergillus The slow destruction process of the lungs
.
It is characterized by local infiltration of lung tissue
.
There is no need for pre-existing voids, although fungal ball voids may be a secondary manifestation of fungal destruction
.
It is also different from invasive aspergillosis in that CNA is a long-term process that takes months to years to develop slowly, and it does not infiltrate blood vessels or spread to other organs
.
CNA generally affects middle-aged and elderly patients and patients with underlying lung diseases (chronic obstructive pulmonary disease, inactive tuberculosis, previous pneumonectomy, radiotherapy, cystic fibrosis, pulmonary infarction)
.
Patients with mild immunosuppression can also be affected, such as diabetes, connective tissue diseases (rheumatoid arthritis and ankylosing spondylitis, etc.
), malnutrition, and the use of low-dose corticosteroids
.
Clinical features include fever, cough, sputum expectoration, and weight loss from 1 to 6 months
.
Chest X-rays usually show infiltration of the upper or lower lobe dorsal segment
.
Fungal balls can be observed in nearly half of the cases
.
Thickening of the adjacent pleura is a typical manifestation and may be an early indication of local infiltration
.
The following criteria can be used for the clinical diagnosis of CAN: ➤ The clinical and imaging findings are consistent with the diagnosis ➤ Sputum and bronchoscope sample culture and isolation of Aspergillus ➤ Excluding other diseases with similar manifestations, such as active tuberculosis, atypical mycobacterial infection, chronic histoplasmosis coccidioidomycosis or antifungal such as intravenous treatment with amphotericin B
.
However, voriconazole has become an effective alternative medicine
.
Surgical resection is usually used for young patients with focal lesions and good lung function reserves
.
Identifying invasive pulmonary aspergillosis (IPA) is a serious and life-threatening disease that affects patients with long-term severe neutropenia
.
It is most common in patients undergoing hematopoietic stem cell or solid organ transplantation
.
Lung disease is the most common manifestation
.
Difficulty in early diagnosis
.
The sensitivity of bronchoalveolar lavage (BAL) culture in focal lung disease is 50%
.
A clear diagnosis usually requires invasive procedures, but the isolation of Aspergillus from the sputum or BAL of patients with neutropenia can be highly predictive of invasive disease
.
Among patients with neutropenia and hematopoietic stem cell transplantation, the most common manifestations of early IPA on chest CT are single or multiple nodules, and chest X-rays may not be obvious
.
Combining the following items can be diagnosed as "possible invasive aspergillosis", so there is no need for invasive operation testing
.
➤ Susceptible host factors ➤ Consistent clinical and imaging findings ➤ Two consecutive positive serum galactomannan tests.
Although surgery can be used to remove necrotic and infected tissue, the treatment is mainly the use of suitable antifungal agents
.
It is also suitable for pericardial infection, empyema, chest wall infiltration and persistent hemoptysis
.
Surgical removal of the cavity is used for patients with single lung disease, repeated hemoptysis, or overlapping bacterial infections
.
Voriconazole is the main treatment
.
The recommended dose is 6 mg/kg intravenously on the first day, twice a day, then 4 mg/kg intravenously twice a day, and after stabilization is changed to 200 mg orally, twice a day
.
The combination of voriconazole and echinocandin can be used for salvage therapy
.
It is recommended to continue antifungal treatment until the symptoms and signs of infection and imaging evidence disappear for at least 2 weeks
.
Compiled from: Cavitating Lung Lesion and Recurrent ChestInfections-thoracic.
.
.
Male with a medical history, 70 years old, smoked 54 years, is a retired office worker
.
Repeated chest infection for 6 months
.
At first, he coughed with sputum, but later it was dry cough
.
The patient complained: exertional dyspnea, general fatigue, decreased appetite, and weight loss of about 5 kg within six months
.
No hemoptysis, night sweats or fever
.
The patient has ischemic heart disease, coronary artery bypass graft surgery 12 years ago, chronic obstructive airway disease, hypertension and hypercholesterolemia
.
When the patient was 2 years old, his mother died of tuberculosis
.
Therapies include inhaled corticosteroids, long-acting inhaled anticholinergic drugs, low-dose aspirin, ACE inhibitors and statins
.
On physical examination, the pulse rate was 70 bpm and normal
.
No heat, the oxygen saturation in indoor air is 97%
.
Clubbing appeared very early
.
Cardiovascular examination revealed a systolic murmur
.
Respiratory examination showed that the bilateral air intake was reduced, but there was no popping or wheezing
.
Abdominal examination is normal
.
Laboratory examination ➤ Except for eosinophils of 0.
6×109/L (0.
0-0.
4×109/L), the complete blood count is normal .
➤ Erythrocyte sedimentation rate (ESR) is 88 mm/h (1-22 mm/h), and C-reactive protein (CRP) is 60 mg/L (0-10 mg/L)
.
➤ Urea nitrogen, creatinine, electrolytes and liver function tests are normal
.
Based on chest X-ray (Figure 1) and computed tomography (CT) (Figures 2 and 3), further laboratory tests and bronchoscopy were performed: ➤ Serum IgE 2378 ng/ml➤ Aspergillus fumigatus (m3) ) Antibody 12.
1 ng/ml (positive) ➤ Anti-Aspergillus IgG 149 ng/ml (positive) ➤ Antinuclear antibody (negative) ➤ Anti-neutrophil cytoplasmic antibody (negative) ➤ Galactomannan 0.
2 ng/ml ( Positive >0.
5 ng/ml) ➤ Ziel-Nielson staining of acid-fast bacilli negative ➤ Bronchoscopy showed no evidence of intrabronchial lesions ➤ Bronchoalveolar lavage showed Gram-positive cocci and Gram-negative bacilli ➤ Bronchoscopy: No malignant cells, no non-specific inflammatory changes.
Figure 1 PA chest radiograph showing a cavity in the left lung apex
.
Figure 2 CT scan in the supine position
.
Figure 3 CT scan in prone position
.
Combining the above tests, what is the most likely diagnosis? A.
Aspergillus B.
Tuberculosis C.
Malignant tumor D.
Sarcoidosis E.
Klebsiella pneumonia Correct answer: Aspergillus Aspergillus is widely distributed and in nature, it exists in organic matter necrosis, moldy grains, feed, water, soil, In clothes and furniture
.
It is often infected by inhaling spores in the air
.
It grows best at 37°C.
Microspores with a diameter of 2 to 3 µm are easily inhaled and deposited deep in the lungs
.
May cause a variety of clinical symptoms, although the most obvious lung disease
.
The most common cause of lung Aspergillus infection is Aspergillus fumigatus, and a few are Aspergillus flavus
.
Aspergillus is a conditional pathogen.
Inhalation of patients with underlying lung diseases or weakened immune function can cause a variety of diseases
.
Aspergillus grows first in the cavities of the lungs, and the presence of cavities in the lungs is the most common predisposing factor
.
In most cases, the lesion remains stable
.
About 10% of Aspergillus will be relieved or disappear spontaneously without treatment
.
Rarely, the aspergillus ball enlarges
.
Most patients are asymptomatic, sometimes as long as several years, and only accidentally discovered
.
The patient may have hemoptysis, sometimes severe
.
It may manifest as chronic cough or difficulty breathing
.
In radiology, the aspergillus balls are obvious in the upper lobe, the masses in the cavity are active, and there are air crescent signs around them
.
The position of the aspergillus ball changes with the change of the patient's position
.
Sputum culture may show the presence of Aspergillus, but culture is negative in 50% of cases
.
In almost all cases, serum IgG antibodies of Aspergillus are positive; however, false negatives may occur in non-Aspergillus fumigatus patients or patients receiving corticosteroid therapy
.
For asymptomatic patients, no treatment is required
.
There is no consistent evidence that Aspergillus responds to antifungal drugs such as amphotericin B or voriconazole
.
Intracavitary or bronchial antifungal drugs can be used, but this is usually suitable for patients with severe hemoptysis
.
Surgical treatment of Aspergillus is related to a relatively high fatality rate, which ranges from 7% to 23%
.
There are also considerable morbidities after surgery, such as bleeding, pleural disease, bronchopleural fistula, empyema and respiratory failure
.
Further testing: The patient then had shortness of breath and developed a cough and green sputum
.
No fever, there was a crackling sound in the upper left lobe on respiratory examination
.
1.
Laboratory testing ➤ White blood cell count 12.
5x109/L (4-11 x109/L) ➤ Neutrophils 9.
3x109/L (2.
0-7.
5 x109/L) ➤ Eosinophils 0.
2 x109/L (0.
0-0.
4 x109/L) 2.
Arterial blood gas analysis in indoor air ➤ PO2: 10.
61 kPa (79.
8 mm Hg) ➤ PCO2: 3.
86 kPa (29 mm Hg) ➤ pH: 7.
49 ➤ HCO3: 23.
7 mmol/L 3.
Lung function test ➤ FEV1 56% predicted value ➤ FVC 80% predicted value ➤ FEV1/FVC 53% ➤ TLC 84% predicted value ➤ RV 98% predicted value ➤ DLco 33% predicted value combined with the above, what is the most likely diagnosis? A.
Aspergillus with bacterial infection B.
Malignant tumor C.
Chronic necrotizing aspergillosis D.
Invasive pulmonary aspergillus E.
A and C Correct answer: E Chronic necrotizing aspergillosis (CNA) is caused by the invasion of Aspergillus The slow destruction process of the lungs
.
It is characterized by local infiltration of lung tissue
.
There is no need for pre-existing voids, although fungal ball voids may be a secondary manifestation of fungal destruction
.
It is also different from invasive aspergillosis in that CNA is a long-term process that takes months to years to develop slowly, and it does not infiltrate blood vessels or spread to other organs
.
CNA generally affects middle-aged and elderly patients and patients with underlying lung diseases (chronic obstructive pulmonary disease, inactive tuberculosis, previous pneumonectomy, radiotherapy, cystic fibrosis, pulmonary infarction)
.
Patients with mild immunosuppression can also be affected, such as diabetes, connective tissue diseases (rheumatoid arthritis and ankylosing spondylitis, etc.
), malnutrition, and the use of low-dose corticosteroids
.
Clinical features include fever, cough, sputum expectoration, and weight loss from 1 to 6 months
.
Chest X-rays usually show infiltration of the upper or lower lobe dorsal segment
.
Fungal balls can be observed in nearly half of the cases
.
Thickening of the adjacent pleura is a typical manifestation and may be an early indication of local infiltration
.
The following criteria can be used for the clinical diagnosis of CAN: ➤ The clinical and imaging findings are consistent with the diagnosis ➤ Sputum and bronchoscope sample culture and isolation of Aspergillus ➤ Excluding other diseases with similar manifestations, such as active tuberculosis, atypical mycobacterial infection, chronic histoplasmosis coccidioidomycosis or antifungal such as intravenous treatment with amphotericin B
.
However, voriconazole has become an effective alternative medicine
.
Surgical resection is usually used for young patients with focal lesions and good lung function reserves
.
Identifying invasive pulmonary aspergillosis (IPA) is a serious and life-threatening disease that affects patients with long-term severe neutropenia
.
It is most common in patients undergoing hematopoietic stem cell or solid organ transplantation
.
Lung disease is the most common manifestation
.
Difficulty in early diagnosis
.
The sensitivity of bronchoalveolar lavage (BAL) culture in focal lung disease is 50%
.
A clear diagnosis usually requires invasive procedures, but the isolation of Aspergillus from the sputum or BAL of patients with neutropenia can be highly predictive of invasive disease
.
Among patients with neutropenia and hematopoietic stem cell transplantation, the most common manifestations of early IPA on chest CT are single or multiple nodules, and chest X-rays may not be obvious
.
Combining the following items can be diagnosed as "possible invasive aspergillosis", so there is no need for invasive operation testing
.
➤ Susceptible host factors ➤ Consistent clinical and imaging findings ➤ Two consecutive positive serum galactomannan tests.
Although surgery can be used to remove necrotic and infected tissue, the treatment is mainly the use of suitable antifungal agents
.
It is also suitable for pericardial infection, empyema, chest wall infiltration and persistent hemoptysis
.
Surgical removal of the cavity is used for patients with single lung disease, repeated hemoptysis, or overlapping bacterial infections
.
Voriconazole is the main treatment
.
The recommended dose is 6 mg/kg intravenously on the first day, twice a day, then 4 mg/kg intravenously twice a day, and after stabilization is changed to 200 mg orally, twice a day
.
The combination of voriconazole and echinocandin can be used for salvage therapy
.
It is recommended to continue antifungal treatment until the symptoms and signs of infection and imaging evidence disappear for at least 2 weeks
.
Compiled from: Cavitating Lung Lesion and Recurrent ChestInfections-thoracic.
