Vol 39 # 2 June 2007 - Kma.org.kw

KUWAIT MEDICAL JOURNAL June 2007Case ReportAspergillus Pseudomembranous TracheobronchitisComplicating Treatment of COPD ExacerbationsAlia Al-Alawi 1 , Frank Ryan 21Department of Medicine, Amiri Hospital, Kuwait2Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, CanadaABSTRACTKuwait Medical Journal 2007, 39 (2):184-187Aspergillus pseudomembranous tracheobronchitis is anuncommon form of invasive aspergillosis that affectsimmuno-compromised hosts. We describe the clinicaland radiological features of this form of invasiveaspergillosis occurring in two patients with severe COPDas a complication of treatment with corticosteroids andbroad spectrum antibiotics.KEY WORDS: aspergillosis, COPD, tracheobronchitisINTRODUCTIONA s p e rgillus pseudomembranous tracheobro n c h i t i sis a form of invasive pulmonary aspergillosis that islimited to the tracheobronchial tree. Aspergillushyphae invade the airways and form plugs that canlead to airway obstruction. It occurs most commonlyin neutropenic patients receiving chemotherapybut has also been described following org a ntransplantation, viral infections (particularly influenza),diabetes mellitus, renal and hepatic failure and inpatients with acquired immunodeficiency syndro m e .In addition to these underlying diseases, a historyof treatment with corticosteroids and antibiotics iscommon. Patients usually present with dyspnea,cough and wheezing. They occasionally expectoratemucus plugs or tracheobronchial casts. The diagnosisis confirmed by demonstrating fungal invasion ofthe airways. The condition is associated with a highmortality rate despite treatment. There are threep revious case reports of aspergillus tracheobro n c h i t i soccurring in patients with COPD. We report twofurther cases, describe their clinical and radiologicalfeatures and speculate on the role of corticostero i dt h e r a p y, broad spectrum antibiotics and possiblyantecedent viral respiratory tract infection in theo c c u r rence of this rare, but frequently lethal,complication of COPD exacerbations.Case 1A 6 7 - y e a r-old female cigarette smoker withknown COPD presented to hospital in the fall of1998 with increasing shortness of breath. A chestradiograph showed evidence of hyperinflation ofthe lungs but no infiltrates. She was admitted witha diagnosis of COPD exacerbation and was treatedempirically with bronchodilators, systemicc o r t i c o s t e ro i d s and cefuroxime. Erythro m y c i nwas added later because of failure to improve.S p i rometry showed an FEV1 of 0.65L ( 3 1 %predicted).The patient continued to deteriorate. Shedeveloped herpes labialis and a painful red eye,subsequently confirmed to be herpes simplexkeratitis. She also had oral candidiasis. A follow-upchest radiograph 12 days later showed poorlydefined bilateral nodular opacities (Fig. 1). Highresolution CT of the chest (Fig. 2) demonstratedextensive bilateral centrilobular nodular andbranching linear opacities (tree-in-bud pattern).Also noted were a few randomly distributednodules measuring 5 to 10 mm in diameter andpatchy bilateral ground glass opacities. Bronchialwall thickening was present involving mainly thesegmental and subsegmental bronchi of the upperlobes. Bronchoscopy revealed pharyngeal candidiasisand extensive membranous, slightly hemorrhagicexudates throughout the trachea and pro x i m a lmain-stem bronchi. The membrane was adherentand attempted suction caused slight bleeding. Thewashings showed the psuedomembrane to containA s p e rg i l l u sand cultures grew A s p e rg i l l u sf u m i g a t u s .Tr a n s b ronchial and endobronchial biopsies confirmedthe presence of inflammatory psuedomembraneswithin which were fungal elements morphologicallyAddress Correspondence to:Dr. Alia Al-Alawi, P.O. Box 3876- Mushrif-40190, Kuwait. Tel : 965 245 0005, Fax: 965 244 7584, E-mail: aliamed@yahoo.com