Case report/Cas clinique
Diagnosis of airway-invasive pulmonary aspergillosis by tree-in-bud sign in an immunocompetent patient: Case report and literature reviewDiagnostic d’une aspergillose pulmonaire invasive par le symptôme de l’arbre en bourgeon chez un patient immunocompétent : cas clinique et revue de la littérature

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Summary

Invasive fungal infections are rare in immunocompetent hosts, and diagnosis may be missed or delayed due to our lack of understanding of the particular clinical signs, disease progression, and treatment outcome. Here, we present a case of pulmonary invasive aspergillosis that arose in an immunocompetent and previously healthy patient. The patient presented with a several-week history of remittent high fever, cough, and expectoration. These symptoms were unresponsive to treatments for tuberculosis and pulmonary bacterial infection. Computed tomography images revealed the characteristic bronchiolitis tree-in-bud pattern in the airways. Lung biopsy specimens were culture-positive for Aspergillus fumigatus. Treatment with voriconazole and caspofungin followed by amphotericin B cleared the infection and resolved the symptoms.

Résumé

Les infections fongiques invasives sont rares chez les hôtes immunocompétents et le diagnostic peut être erroné ou retardé en raison de notre manque de compréhension des signes cliniques particuliers, de la progression de la maladie et des résultats du traitement. Ici, nous présentons un cas d’aspergillose pulmonaire invasive qui a surgi chez un patient immunocompétent et auparavant en bonne santé. Le patient s’est présenté avec une histoire de plusieurs semaines de fièvre rémittente, de toux forte et d’expectoration. Ces symptômes n’ont pas répondu aux traitements pour tuberculose pulmonaire et pour infection bactérienne. Les images de tomographie ont révélé une bronchiolite caractéristique avec aspect d’arbre en bourgeon de la radiographie des voies respiratoires. Les biopsies ont révélé la présence d’Aspergillus fumigatus après culture. Le traitement par le voriconazole et la caspofungine suivi par l’amphotéricine B a éliminé l’infection et les symptômes correspondants.

Introduction

Aspergillus spp. is a saprophytic, aerobic, and ubiquitous fungus family. Infection of human hosts occurs by inhalation of the airborne spores, which are ∼1–3 μm in size. The particular manifestations of pulmonary aspergillosis are determined by the host's immune status, and have been categorized as follows: saprophytic aspergillosis (aspergilloma), allergic bronchopulmonary aspergillosis (ABPA), semi-invasive aspergillosis (chronic necrotizing pulmonary aspergillosis, CNPA), and invasive pulmonary aspergillosis (IPA; airway-invasive and angio-invasive aspergillosis) [2], [6]. Among these four categories, IPA is the most severe and has emerged as a major cause of mortality in severely immunocompromised patients, especially those with neutropenia. However, very few cases of IPA in apparently immunocompetent patients have been reported in the literature. As a result, the features of IPA in immunocompetent individuals, its disease course and outcome remain to be fully defined. Here, we report a case of airway-invasive aspergillosis in an immunocompetent patient. The key diagnostic features were unresponsiveness to antibacterial treatment, computed tomography (CT) detection of the tree-in-bud sign, and Aspergillus fumigatus-positive culture of the lung biopsy specimen.

Section snippets

Case presentation

A 24-year-old man from China's Anhui Province was admitted to the hospital with a half-month history of remittent high fever, cough, and expectoration that had been unresponsive to empirical treatment for tuberculosis and pulmonary bacterial infection before hospitalization. The patient reported no exposure to musty or dusty conditions that may have instigated or exacerbated the symptoms. The patient reported no history of alcohol abuse or smoking.

On physical examination at admission, the

Discussion

Chemotherapy-induced immunosuppression is a recognized risk factor of invasive aspergillosis. Other disorders and therapeutic interventions that are associated with increased risk of IPA include corticosteroid usage, prolonged neutropenia, chronic obstructive pulmonary disease and cytomegalovirus infection. Organ transplant recipients represent another group at high risk for developing infections with opportunistic and pathogenic microbes, such as fungi, due to the required immunosuppression to

Conclusion

Here, we report a case of pulmonary aspergillosis in an immunocompetent patient who was diagnosed according to CT findings of diffuse, small centrilobular nodules, cavity formation, and bronchiolitis associated with thickened bronchial walls. GM test results were discordant from the patient's clinical features. Amphotericin B was an effective second-line therapy following first-line combination of caspofungin and voriconazole.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

References (7)

  • A.O. Soubani et al.

    The clinical spectrum of pulmonary aspergillosis

    Chest

    (2002)
  • T.R. Dagenais et al.

    Pathogenesis of Aspergillus fumigatus in invasive aspergillosis

    Clin Microbiol Rev

    (2009)
  • T. Franquet et al.

    Spectrum of pulmonary aspergillosis: histologic, clinical and radiologic findings

    Radiographics

    (2001)
There are more references available in the full text version of this article.

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