Selected Reports - Chest - American College of Chest Physicians

CHEST Selected Reports 

Cavitating Invasive Pulmonary 

Aspergillosis Visualized and 

Diagnosed by Ultrathin 

Bronchoscopy* 

Masahide Oki, MD; Hideo Saka, MD, FCCP; 

Chieko Sako, MD; Shigeru Tanaka, MD; 

Yoshihiro Kawata, MD; Chiyoe Kitagawa, MD; and 

Nobuyoshi Minemura, MD 

A definitive diagnosis of invasive pulmonary aspergillosis 

(IPA), which usually occurs in immunocompromised 

patients, is often difficult. We report 

two cases of cavitating IPA in a peripheral pulmonary 

region in patients who were receiving corticosteroids, 

in whom the cavity was successfully visualized 

and sampled during ultrathin bronchoscopy. 

Ultrathin bronchoscopy provides a new option for 

definitive diagnosis of cavitating IPA. 

(CHEST 2006; 129:475–479) 

Key words: bronchoscopy; cavity; invasive pulmonary aspergillosis; 

transbronchial biopsy; ultrathin bronchoscope 

Abbreviations: IPA invasive pulmonary aspergillosis; 

TBB transbronchial biopsy 

Invasive pulmonary aspergillosis (IPA), which commonly 

occurs in immunocompromised patients, is a lifethreatening 

infectious disease. Not only are such patients 

difficult to treat, the diagnosis is especially difficult. 

Although bronchoscopic procedures such as BAL and 

transbronchial biopsy (TBB) have been used to establish 

the diagnosis of IPA, their diagnostic yield is insufficient. 1 

The diagnostic yield of TBB is particularly low, 2 so its 

value for the diagnosis of IPA remains controversial. 3 

Recently, ultrathin bronchoscopes offering a smaller 

outer diameter and higher image quality have been developed. 

Such a bronchoscope with an outer diameter of 2.8 

mm is now commercially available and permits the observation 

and manipulation of more peripheral bronchi than 

was previously possible with a standard bronchoscope. The 

*From the Departments of Respiratory Medicine (Drs. Oki, Saka, 

Sako, Tanaka, Kawata, and Kitagawa) and Internal Medicine (Dr. 

Minemura), Nagoya Medical Center, Nagoya, Japan. 

Manuscript received July 11, 2005; revision accepted August 20, 

2005. 

Reproduction of this article is prohibited without written permission 

from the American College of Chest Physicians (www.chestjournal. 

org/misc/reprints.shtml). 

Correspondence to: Masahide Oki, MD, Department of Respiratory 

Medicine, Nagoya Medical Center, 4-1-1 Sannomaru, Nakaku, 

Nagoya 460-0001, Japan; e-mail: Masahideo@aol.com 

ultrathin bronchoscope has been reported to be a valuable 

diagnostic tool for peripheral pulmonary lesions. 4–6 Although 

various diseases can be diagnosed histologically 

using the ultrathin bronchoscope, there is, to our knowledge, 

no report in the literature about its contribution to 

the diagnosis of IPA. We herewith report two cases of IPA 

diagnosed in patients were receiving corticosteroids, in 

whom the cavity was visualized and sampled during 

ultrathin bronchoscopy. 

Case 1 

Case Reports 

A 57-year-old man with dermatomyositis was referred for 

bronchoscopic evaluation of progressive radiographic changes 

consisting of an enlarging cavity despite antibiotic therapy. For 3 

months, he had received prednisolone, 40 to 80 mg/d, and 

azathioprine, 100 mg/d, for intractable dermatomyositis. Two 

weeks earlier, he complained of fever, increased cough, purulent 

sputum, and dyspnea. The chest radiograph showed a cavity with 

surrounding infiltrates in the upper lobe of the right lung. 

Sputum cultures grew Pseudomonas aeruginosa and Candida 

glabrata. The patient had been treated with IV cefozopran and 

fluconazole for 2 weeks without any clinical improvement. 

A CT scan of the chest the day before bronchoscopy revealed 

a thick wall cavity in the anterior segment of the right upper lobe 

that had not been present 2 months previously (Fig 1). Bronchoscopic 

examination using a standard bronchoscope with an 

external diameter of 6.1 mm (BF-6C240; Olympus; Tokyo, Japan) 

[Fig 2] was first performed. The bronchoscope reached the 

segmental bronchus of the right upper lobe and revealed no 

abnormalities. Then, for peripheral investigation, a 2.8 mm in 

diameter ultrathin bronchoscope with a 1.2-mm working channel 

(BF-XP40; Olympus) [Fig 2] was employed. The ultrathin bronchoscope 

was inserted into the right B3 and advanced through 

the fifth-generation bronchus under direct observation, and then 

entered a cavity, as confirmed by fluoroscopy (Fig 3). A whitish 

intracavitary lesion was seen (Fig 4, left, A). Biopsies using a 

miniforceps (FB-56D-1; Olympus) and washing were performed 

with bronchoscopic visualization, and then amphotericin B, 5 mg, 

was instilled into the cavity through the ultrathin bronchoscope 

for treatment of a presumptive fungal infection. Biopsy specimens 

showed septate-branching hyphae suggestive of aspergillosis 

and cultures of the cavital washing grew Aspergillus flavus. 

Unfortunately, 9 days later the patient suddenly died of cerebral 

hemorrhage. 

Case 2 

A 69-year-old man with systemic lupus erythematosus was 

admitted to the hospital with cough, bloody sputum, fatigue, 

decreased appetite, and enlarging left lower lobe pulmonary 

cavity. For 6 months before hospital admission, he had received 

prednisolone, 20 to 30 mg/d, for systemic lupus erythematodes. 

Two months earlier, he complained of bloody sputum, and a 

chest CT showed cavitary infiltrates in the superior segment of 

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Figure 1. Chest CT on the day before bronchoscopy showed a thick wall cavity in the anterior segment 

of the right upper lobe (right) that had not been present 2 months previously (left). 

the left lower lobe (Fig 5, left). Sputum cultures showed A flavus. 

Clinical deterioration with an enlarging cavity had occurred 

despite antibiotic treatments including itraconazole (Fig 5, right). 

Bronchoscopic examination was performed using a 2.8-mm 

ultrathin bronchoscope (BF-XP260F; Olympus), which could be 

inserted into the seventh-generation bronchus under direct vision 

and then advanced into the cavity. A yellowish white intracavitary 

lesion was noted (Fig 4, right, B). Biopsies and washing were 

Figure 2. A comparison of bronchoscopes. Left: a standard bronchoscope with an external diameter 

of 6.1 mm and a working channel of 2.0 mm (BF-6C240; Olympus); right: an ultrathin bronchoscope 

with an external diameter of 2.8 mm and a working channel of 1.2 mm (BF-XP40; Olympus). 

476 Selected Reports 


Figure 3. Tip of the ultrathin bronchoscope shown entering a 

cavity. 

performed under ultrathin bronchoscopic visualization. Histologic 

examination of biopsy specimens showed septate-branching 

hyphae, and cultures of the cavital washing grew Aspergillus 

fumigatus. IV amphotericin B was administered at a total dose of 

2,000 mg, and the patient showed clinical improvement with 

resolution of the extracavitary and intracavitary infiltrates but 

persistence of a thin wall cavity. 

Discussion 

IPA occurs mainly in severely immunocompromised 

patients, particularly those with prolonged severe granu- 

locytopenia. 7 Although the incidence is relatively uncommon, 

mildly immunocompromised patients, such as those 

receiving corticosteroids similar to our cases, can also 

acquire IPA. 8,9 Palmer et al 9 reported six patients with 

lung disease receiving corticosteroids who acquired IPA, 

and they indicated that IPA should be included in the 

differential diagnosis when pneumonia and cavitary infiltrates 

occur in such patients. 

Although the diagnosis of IPA is often admittedly 

difficult, 10 when compatible clinical and radiographic findings 

are supported by the presence of positive culture 

results for Aspergillus species from respiratory secretions, 

it is highly likely that the patient has IPA. BAL during 

bronchoscopy has proved helpful in diagnosing IPA. In 

one review article, 11 it was reported that the diagnostic 

sensitivity of BAL was 43% in histologically proven IPA. 

However, the reported diagnostic sensitivity of BAL for 

IPA appears to vary with the investigator. Saito et al 12 

reported that BAL was diagnostic for pulmonary aspergillosis 

in none of nine patients with leukemia. Most specific 

diagnoses for pulmonary aspergillosis were established 

solely from autopsy, so BAL was reportedly useless in most 

cases. Moreover, the specificity of BAL for IPA is good, 

but it may be difficult to exactly distinguish infection from 

colonization. 

The definitive diagnosis of IPA requires histopathologic 

demonstration of septate acute branching hyphae with 

positive culture results for Aspergillus. 13 TBB is a safe and 

established bronchoscopic method in the histopathologic 

diagnosis of pulmonary infections in immunocompromised 

patients. As for diagnosing IPA, however, the 

diagnostic sensitivity of TBB has been reported to be quite 

low. 2 Some authors 14,15 advocate the use of invasive surgical 

procedures for the diagnosis and treatment of IPA. In 

our case 2, the clinical and radiologic progress was relatively 

less acute, and the immunosuppression was mild, so 

it might be categorized as subacute IPA. However, a 

Figure 4. Ultrathin bronchoscopic views of the lung cavity. A whitish intracavitary lesion caused by A 

flavus was seen in case 1 (left, A), and a yellowish white lesion caused by A fumigatus was seen in case 

2(right, B). 



Figure 5. A cavity in the superior segment of the left lower lobe shows enlargement (right) compared 

to 2 months previously (left). 

precise distinction has not been made between IPA and 

other chronic forms of Aspergillus, such as subacute IPA 

or chronic necrotizing pulmonary aspergillosis. Moreover, 

the diagnostic yield of TBB for chronic cavitary pulmonary 

aspergillosis has also been reported to be quite low. 16 

A commercially available ultrathin bronchoscope with 

an external diameter of 2.8 mm has been used as a 

diagnostic 4–6 and therapeutic tool 17 in the peripheral 

airways. It can reach the peripheral area of the lung and 

occasionally even the visceral pleura. 18 Nevertheless, the 

closer the ultrathin bronchoscope is brought to the peripheral 

bronchi, the poorer the visibility is. Soft peripheral 

bronchi, which easily collapse under bronchoscopic 

suction, and bronchial secretions obstruct the visibility. 

However, a cavitary lesion in the peripheral area of the 

lung may be a good indication for ultrathin bronchoscopy. 

Once the tip of the ultrathin bronchoscope enters the 

cavity through a small bronchus, the range of vision 

becomes broad. Biopsy of a lesion with bronchoscopic 

visualization should result in higher diagnostic yield. 

Moreover, a biopsy with direct visualization using miniforceps 

may decrease the risks of bleeding. 

Visualization of intracavitary lesions during bronchoscopy 

in patients with pulmonary aspergillosis, mostly 

aspergilloma, which is characterized by mycelial growth in 

a preexisting lung cavity and usually has a good prognosis 

without any treatments, has been rarely reported. 19–21 

However, there may be only a limited number of cases in 

which the diameter of the bronchus leading to the cavity is 

relatively large. In our case 1, a conventional bronchoscope 

could reach no farther than the segmental bronchus. 

Our results indicate an ultrathin bronchoscope can enter a 

cavity more frequently than a conventional bronchoscope. 

In some cases, it appears that ultrathin bronchoscopy can 

be useful in the diagnosis of cavitating IPA. Further 

studies are needed to elucidate in more detail its utility for 

the diagnosis of IPA. 

References 

1 Reichenberger F, Habicht J, Matt P, et al. Diagnostic yield of 

bronchoscopy in histologically proven invasive pulmonary 

aspergillosis. Bone Marrow Transplant 1999; 24:1195–1199 

2 Albelda SM, Talbot GH, Gerson SL, et al. Role of fiberoptic 

bronchoscopy in the diagnosis of invasive pulmonary aspergillosis 

in patients with acute leukemia. Am J Med 1984; 

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3 Stevens DA, Kan VL, Judson MA, et al. Practice guidelines 

for diseases caused by Aspergillus: Infectious Diseases Society 

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peripheral lesions using ultrathin bronchoscope. J Jpn Soc 

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5 Shinagawa N, Yamazaki K, Onodera Y, et al. CT-guided 

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virtual bronchoscopic navigation. Chest 2004; 125:1138–1143 

6 Yamamoto S, Ueno K, Imamura F, et al. Usefulness of 

ultrathin bronchoscopy in diagnosis of lung cancer. Lung 

Cancer 2004; 56:43–48 

7 Gerson SL, Talbot GH, Hurwitz S, et al. Prolonged granulocytopenia: 

the major risk factor for invasive pulmonary aspergillosis 

in patients with acute leukemia. Ann Intern Med 

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8 Karam GH, Griffin FM. Invasive pulmonary aspergillosis in 

478 Selected Reports 


nonimmunocompromised, nonneutropenic hosts. Rev Infect 

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9 Palmer LB, Greenberg HE, Schiff MJ. Corticosteroid treatment 

as a risk factor for invasive aspergillosis in patients with 

lung disease. Thorax 1991; 46:15–20 

10 Denning DW, Marinus A, Cohen J, et al. An EORTC 

multicentre prospective survey of invasive aspergillosis in 

haematological patients: diagnosis and therapeutic outcome. 

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1998; 37:173–180 

11 Reichenberger F, Habicht JM, Gratwohl A, et al. Diagnosis 

and treatment of invasive pulmonary aspergillosis in neutropenic 

patients. Eur Respir J 2002; 19:743–755 

12 Saito H, Anaissie EJ, Morice RC, et al. Bronchoalveolar 

lavage in the diagnosis of pulmonary infiltrates in patients 

with acute leukemia. Chest 1988; 94:745–749 

13 Tablan OC, Anderson LJ, Besser R, et al. Guidelines for 

preventing health-care-associated pneumonia, 2003: recommendations 

of CDC and the Healthcare Infection Control 

Practices Advisory Committee. MMWR Morb Mortal Wkly 

Rep Recomm Rep 2004; 53:1–36 

14 Baron O, Guillaume B, Moreau P, et al. Aggressive surgical 

management in localized pulmonary mycotic and nonmycotic 

infections for neutropenic patients with acute leukemia: 

report of eighteen cases. J Thorac Cardiovasc Surg 1998; 

115:63–69 

15 Reichenberger F, Habicht J, Kaim A, et al. Lung resection for 

invasive pulmonary aspergillosis in neutropenic patients with 

hematologic diseases. Am J Respir Crit Care Med 1998; 

158:885–890 

16 Denning DW, Riniotis K, Dobrashian R, et al. Chronic 

cavitary and fibrosing pulmonary and pleural aspergillosis: 

case series, proposed nomenclature change, and review. Clin 

Infect Dis 2003; 37:265S–280S 

17 Oki M, Saka H, Kumazawa A, et al. Extraction of peripheral 

endobronchial foreign body using an ultrathin flexible bronchoscope. 

J Bronchol 2004; 11:37–39 

18 Oki M, Saka H, Kitagawa C, et al. Visceral pleural perforation 

in two cases of ultrathin bronchoscopy. Chest 2005; 127: 

2271–2273 

19 Hargis JL, Bone RC, Stewart J, et al. Intracavitary amphotericin 

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Closure of a Bronchopleural 

Fistula Using Bronchoscopic 

Placement of an Endobronchial 

Valve Designed for the 

Treatment of Emphysema* 

J. Scott Ferguson, MD, FCCP; Kimberly Sprenger, BSN; and 

Timothy Van Natta, MD 

Pneumothoraces are sometimes complicated by a 

persistent air leak or bronchopleural fistula requiring 

prolonged chest tube drainage. Non-surgical 

treatment of persistent bronchopleural fistulas is 

often performed in patients who are poor surgical 

candidates, but the ideal method of closure is not 

known. Here we report closure of a persistent distal 

bronchopleural fistula using a one-way endobronchial 

valve designed for the treatment of emphysema. 

(CHEST 2006; 129:479–481) 

Key words: bronchial fistula; bronchoscopy; pneumothorax 

Abbreviations: BPF bronchopleural fistula; RML right 

middle lobe 

Pneumothoraces are sometimes complicated by a persistent 

air leak or bronchopleural fistula (BPF) requiring 

prolonged chest tube drainage. It is generally recommended 

that surgical treatment be undertaken when possible. However, 

many patients are very poor surgical candidates. In this 

article, we report the successful closure of a prolonged air 

leak with a one-way endobronchial valve originally designed 

for the palliative treatment of emphysema. 

Case Report 

A 63-year-old man with widely metastatic breast cancer was 

admitted for sudden onset of severe dyspnea 8 days after 

thoracoscopic placement of an indwelling cuffed pleural catheter. 

A large hydropneumothorax was discovered, and the indwelling 

catheter was connected to suction, relieving the dyspnea. A chest 

tube was then placed and connected to a water-seal device. A 

large air leak was noted with each exhalation and continued for 

the next 9 days. A new chest tube was placed, but the air leak 

continued. 

The etiology of the pneumothorax was not certain but was 

assumed to be a delayed complication of the thoracoscopy, as 

opposed to necrosis and breakdown of a metastatic focus of tumor. 

A thin-section, multidetector CT scan of the chest revealed multiple 

metastases, hydropneumothorax, and airspace disease of the lower 

lobes. No radiographic evidence of BPF was present. 

Surgical correction with plication of the offending lobe was 

considered but judged to be risky given that the patient’s pulmonary 

reserve was limited due to the metastatic disease. Endoscopic 

therapies with glue, gel foam, and coiling were considered but were 

judged to have a low likelihood of success based on the endoscopist’s 

previous experience with these methods in other patients. Therefore, 

these techniques of BPF closure were not attempted in this 

patient. 

One-way endobronchial valves for the treatment of emphysema 

became available in the United States last year as part of a national 

clinical trial. 1 We thought placement of an endobronchial valve that 

would allow escape of air from the offending segment or lobe, but 

*From Carver College of Medicine, Departments of Internal 

Medicine (Dr. Ferguson and Ms. Sprenger) and Thoracic and 

Cardiovascular Surgery (Dr. Van Natta), University of Iowa, Iowa 

City, IA. 

Dr. Ferguson, Ms. Sprenger, and Dr. Van Natta were supported in 

part by the Endobronchial Valve for Emphysema Palliation Trial 

(VENT) Trial. 

Manuscript received August 31, 2005; revision accepted October 1, 

2005. 

Reproduction of this article is prohibited without written permission 

from the American College of Chest Physicians (www.chestjournal. 

org/misc/reprints.shtml). 

Correspondence to: J. Scott Ferguson, MD, Department of Internal 

Medicine, C-33 GH 200, Hawkins Dr, Iowa City, IA 52242; 

e-mail: john-s-ferguson@uiowa.edu

Selected Reports - Chest - American College of Chest Physicians

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