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Murayama et al 1recently suggested that Aspergillus fumigatus may possess the ability to inhibit phagocyte function. We report a patient with transient neutropenia in whomA fumigatus was present in the sputum. She had a productive cough of two months’ duration and presented with seven days of fever, sweats, myalgia, fatigue, and right supraclavicular swelling. There was no significant past history except smoking. Apart from supraclavicular lymphadenopathy the examination was normal. She was leukopenic (2.3 × 109/1) and neutropenic (0.96 × 109/1). The CD4 count was normal (1.44 × 109/1) and levels of C reactive protein (CRP) were 57 mg/l (normal <10). The chest radiograph and abdominal ultrasound were normal and blood and throat cultures were negative. A heavy growth ofA fumigatus was found in the sputum without evidence of any other infection. HIV testing was negative. Despite a negative monospot test, Epstein-Barr virus (EBV) IgM was detected. Initial EBV IgG and EBNA were negative. The patient remained neutropenic for one week. EBV IgG was detected after two months.
Neutropenia is uncommon but well described during acute EBV infection. It is usually mild and self-limiting though fatalities associated with bacterial sepsis or pneumonia have been reported.2 A fumigatus is an ubiquitous mould.3 In immunocompetent patients it is an incidental finding. In immunocompromised patients it may cause serious infections, most commonly in acute leukaemia, bone marrow transplantation, and prolonged and intense neutropenia. This patient presented with a glandular fever-like illness, neutropenia, and a heavy sputum growth ofA fumigatus. This was a confusing finding and HIV seroconversion illness was considered. However, with the rise in neutrophil count after one week A fumigatus disappeared from the sputum and the patient recovered. Acute EBV infection was confirmed serologically.
Neutropenia is uncommon in infectious mononucleosis but may occasionally precipitate bacterial co-infection. EBV should therefore be considered in any unexplained neutropenia, and may here have facilitated the colonisation of this patient’s respiratory tract withA fumigatus.
author’s reply Drs Schmid and Green present an interesting case and speculate that transient peripheral neutropenia caused by EBV infection may have facilitated the colonisation of this patient’s respiratory tract with Aspergillus fumigatus.
We would not necessarily agree with their speculation. In our paper1-1 we suggested that A fumigatus produces a variety of substances, some of which may suppress antifungal (anti-A fumigatus) activity of human phagocytes including neutrophils and alveolar macrophages in localised regions around the proliferatingAspergillus hyphae. It has been considered that selective protection againstAspergillus conidia by mononuclear phagocytes, especially alveolar macrophages, and againstAspergillus hyphae by neutrophils are critical host defences. In addition, mucociliary clearance should also play an important part in eradicating the fungi from the airways. It is therefore more likely that impairment of the mucociliary clearance associated with underlying bronchopulmonary disorders such as bronchiectasis, healed tuberculosis, and suppression of macrophage function is more closely related to the colonisation of the respiratory tract with A fumigatus than with peripheral neutropenia alone.