Mayo Clinic Proceedings
Chronic Necrotizing Pulmonary Aspergillosis: Pathologic Outcome After Itraconazole Therapy

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Objective

To characterize chronic necrotizing pulmonary aspergillosis (CNPA) clinically, radiographically, and pathologically and to describe its response to treatment.

Material and Methods

We present three cases of well-documented CNPA and detail the long-term clinical and pathologic responses to the new antifungal triazole, itraconazole.

Results

Although all three patients had an appreciable clinical response to itraconazole therapy, tissue obtained at the time of operation or autopsy revealed residual CNPA despite 5 to 12 months of treatment. Even though pathologic resolution of the CNPA did not occur, patient prognosis was determined solely by comorbid illness.

Conclusion

Itraconazole seems to be effective in CNPA when used in a suppressive (rather than curative) role in patients with limited life expectancy.

Section snippets

MATERIAL AND METHODS

Three cases of cavitary CNPA were identified. Antemortem diagnosis was based on the criteria of Binder and coworkers2 and Gefter and associates.1 All patients had a compatible clinical history, subacute to chronic disease course, and pulmonary cavitation with or without infiltrates on a chest roentgenogram. Aspergillus was the sole pathogen isolated from sputum and bronchial washings or transthoracic needle aspirate. CNPA was confirmed histologically in all cases—by lobectomy in one and autopsy

RESULTS

Three cases of CNPA were identified; two were caused by A. fumigatus, and one was caused by A. flavus. All cases were diagnosed and treated by one of us. Itraconazole was administered as 200 mg orally twice a day for a duration that varied from 5 months to 1 year. All patients took itraconazole with meals and refrained from using H2 blockers and over-the-counter antacids during treatment. Details about the clinical and pathologic response to itraconazole are summarized in the subsequent

REPORT OF CASES

Case 1.—A 71-year-old male smoker with long-standing chronic obstructive pulmonary disease (COPD) sought medical assistance in 1991 because of a 2-month history of a cough productive of blood-tinged phlegm. His past medical history was pertinent for a lobectomy (left upper lobe) in 1982 for a stage I squamous cell carcinoma of the lung. After the operation, the patient continued to smoke and had periodic follow-up examinations and chest x-ray studies ordered by his referring physician.

In 1988,

DISCUSSION

In the 1980s, CNPA was described as a distinct type of pulmonary aspergillosis by both Gefter and associates1 and Binder and colleagues.2 Gefter and associates1 used the term semi-invasive aspergillosis to emphasize a disease process overlapping the extremes of colonization and frankly invasive disease. In reviewing the literature, Binder and colleagues2 cited case reports consistent with CNPA as far back as 1921. The terminology used to describe these cases included “primary pulmonary

CONCLUSION

Ultimately, the role of itraconazole in CNPA will require further study with larger numbers of patients, different drug doses and treatment durations, and more clearly defined endpoints. In addition, autopsy studies should be performed in all evaluable patients to obtain objective confirmation of the disease process and the results of therapy. Currently, no individual therapy for CNPA can be recommended as clearly superior to another. Because itraconazole improved patients symptomatically but

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    The views expressed herein are those of the authors and do not purport to reflect the views of the US Army or the Department of Defense.

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