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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 57-59

Pleuropulmonary aspergillosis presenting as hydropneumothorax in second trimester pregnancy


1 Department of Respiratory Medicine, Apollo Main Hoapital, Chennai, Tamil Nadu, India
2 Department of Obstetrics and Gynaecology, Apollo Main Hoapital, Chennai, Tamil Nadu, India
3 Department of Infectious Diseases, Apollo Main Hoapital, Chennai, Tamil Nadu, India

Date of Web Publication3-Jan-2019

Correspondence Address:
Dr. L Sundararajan
Apollo Main Hospitals, No 21, Greams Lane, Off Greams Road, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrc.ijrc_27_18

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  Abstract 


Pleuropulmonary aspergillosis is a rare entity and usually occurs in a patient with preexisting lung disease or surgery. A 29-year-old pregnant woman with 16 weeks of gestation presented with shortness of breath, right-sided chest pain, and productive cough of 2 weeks' duration. A chest radiograph done with abdominal shield revealed right hydropneumothorax. Intercostal drainage insertion was done under ultrasound guidance. Pleural fluid was exudative with high adenosine deaminase levels, and GeneXpert test was negative for Mycobacterium tuberculosis. Pleural fluid and sputum culture revealed significant growth of Aspergillus fumigatus. She was treated with voriconazole intravenously followed by oral route. The patient improved clinically with good lung expansion, and she delivered a normal live baby by elective cesarean section. We report this case in view of the rarity of pleuropulmonary aspergillosis occurring in a young pregnant female with no evidence of prior lung pathology.

Keywords: Aspergillus fumigatus, breathlessness, hydropneumothorax, intercostal drainage, pregnancy, voriconazole


How to cite this article:
Chinnasamy S, Sundararajan L, Radhakrishnan C, Nambi P S. Pleuropulmonary aspergillosis presenting as hydropneumothorax in second trimester pregnancy. Indian J Respir Care 2019;8:57-9

How to cite this URL:
Chinnasamy S, Sundararajan L, Radhakrishnan C, Nambi P S. Pleuropulmonary aspergillosis presenting as hydropneumothorax in second trimester pregnancy. Indian J Respir Care [serial online] 2019 [cited 2019 Aug 18];8:57-9. Available from: http://www.ijrconline.org/text.asp?2019/8/1/57/249346




  Introduction Top


Aspergillus infection of the lung manifests as wide spectrum of illnesses in humans depending on the immune status of the host.[1],[2],[3] The most important of these are allergic bronchopulmonary aspergillosis, chronic necrotizing Aspergillus pneumonia, aspergilloma, and invasive aspergillosis.[4],[5] The most frequently identified species are Aspergillus fumigatus and Aspergillus flavus.

Pleuropulmonary aspergillosis is a rarely reported disease. Less than 1% of pleural effusions are caused by fungal infections.[6] Most of the reported cases of pleuropulmonary aspergillosis have been associated with preexisting lung pathology or surgical procedure. It is most commonly associated with tuberculosis and also associated with postpneumonectomy, lobectomy, pleural drainage, and bronchopulmonary fistulas.[7] Delayed or missed Aspergillus infection and ineffective treatment are responsible for mortality due to aspergillosis.[8] Here, we report pleuropulmonary aspergillosis occurring in a young pregnant female, with no preexisting lung disease or lung surgery. An extensive PubMed search revealed no similar case report in the English literature.


  Case Report Top


A 29-year-old pregnant woman with 16 weeks of gestation presented to the emergency department of our hospital with complaints of breathlessness, low-grade fever, productive cough, and right-sided chest discomfort of 2-week duration. She had no history of loss of appetite, loss of weight, and hemoptysis. There was no history of similar illness in the past. There was no prior history of diabetes mellitus, bronchial asthma, surgical intervention, or hospitalization.

On general examination, the patient's respiratory rate was 28/min; other vitals were stable. Respiratory examination revealed decreased right-sided chest movements, percussion note was stony dull at right base, and air entry was absent at right base.

Her hematological and biochemical parameters were normal. Serology for human immunodeficiency virus was negative. A chest radiograph was done, which had features of right-side hydropneumothorax [Figure 1]. Computed tomography chest was not done in view of radiation hazard to the fetus. Ultrasonography (USG) of the chest revealed loculated pleural fluid collection in the posterolateral aspect of the right lower hemithorax [Figure 2]. USG-guided thoracentesis was done which revealed frank brownish fluid following which tube thoracostomy was performed. Pleural fluid was exudative with high adenosine deaminase, and GeneXpert was negative for Mycobacterium tuberculosis (MTB). Pleural fluid and sputum culture revealed significant growth of A. fumigatus. Sputum was negative for other pyogenic organisms and acid-fast bacilli. Sputum for GeneXpert MTB was also negative. Streptokinase was injected through the intercostal drainage tube for adhesiolysis. The lung expanded well and the intercostal drainage tube was removed after 10 days. Repeat chest X-ray after 2 months showed expanded lung with no lesion [Figure 3]. She was treated with intravenous voriconazole initially followed by oral voriconazole. Her voriconazole trough levels and liver function were monitored periodically. She tolerated voriconazole well without any side effects. After 5 months of voriconazole, she delivered a normal live baby by elective cesarean section.
Figure 1: Chest X-ray showing right-sided hydropneumothorax with right midzone ill-defined parenchymal opacity

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Figure 2: Ultrasonography showing right-sided loculated pleural effusion

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Figure 3: Chest X-ray showing expanded lung after 2 months

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  Discussion Top


Pleuropulmonary aspergillosis is a rare entity and usually occurs in the presence of disruption of local pulmonary defense mechanisms, most often due to tuberculosis. Pleural Aspergillosis was first described by Cleland in 1924.[9] Krakówka et al. found that an established empyema and a bronchopleural or pleurocutaneous fistula were the two clinical settings most commonly associated with pleural Aspergillosis.[10] An extensive PubMed search revealed no case report in English literature, with pleuropulmonary Aspergillosis in pregnant women.

Antifungal agents and surgical procedures have been tried in the treatment of pleuropulmonary aspergillosis. To improve the outcome, pleural drainage and early administration of antifungal agents are recommended.[7] Voriconazole is a broad-spectrum triazole which is active against all species of Aspergillus. It has less adverse effects compared to amphotericin.[11] Stern et al. demonstrated that penetration and sterilization of pleural cavity are good with voriconazole, and within 6 months of treatment, the patient was completely cured.[12] Amphotericin also has been used conventionally, but it has more side effects such as (nephrotoxicity, phlebitis, hypokalemia, hypomagnesemia, and anemia).[11] Liposomal amphotericin comparatively is less nephrotoxic.

Initially, medical termination of pregnancy was considered in our patient because of the difficulty in obtaining appropriate investigations such as computed tomography scan of the chest in a pregnant woman and the need for long-term antifungal for the empyema. Voriconazole belongs to the Food and Drug Administration category D for use in pregnancy, and there were anticipated concerns on the fetus. Moreover, Aspergillosis per se may also affect the baby (e.g., intrauterine infection). All these aspects were discussed in detail with the patient and she decided to continue with the pregnancy.

Organogenesis is the process by which three germ layers turn into the internal organs. This period extends from 3 to 10 weeks of pregnancy. During this period, the fetus is most susceptible to malformations from teratogenic agents. However, in our patient, the period of organogenesis was over when we started antifungal therapy, and serial USGs showed no signs of fetal anomalies. The pregnancy was continued, and termination of pregnancy could be avoided. The patient responded well clinically and radiologically to voriconazole therapy and pleural drainage and delivered a normal live baby.


  Conclusion Top


In nonresponsive empyema, fungal cause also should be included in the differential diagnosis. Early diagnosis and treatment with appropriate antifungals and surgical intervention improves the outcome. Monitoring for the side effects of antifungal therapy is important. The management of pleuropulmonary aspergillosis in pregnancy can often be challenging and requires a dedicated multidisciplinary approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Latgé JP. Aspergillus fumigatus and aspergillosis. Clin Microbiol Rev 1999;12:310-50.  Back to cited text no. 1
    
2.
Dagenais TR, Keller NP. Pathogenesis of Aspergillus fumigatus in invasive aspergillosis. Clin Microbiol Rev 2009;22:447-65.  Back to cited text no. 2
    
3.
Romani L. Immunity to fungal infections. Nat Rev Immunol 2011;11:275-88.  Back to cited text no. 3
    
4.
Buckingham SJ, Hansell DM. Aspergillus in the lung: Diverse and coincident forms. Eur Radiol 2003;13:1786-800.  Back to cited text no. 4
    
5.
Karthik RK, Sudarsanam TD. An unusual cause of empyema thoracis. Indian J Med Sci 2009;63:30-2.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Light RW. Pleural effusion secondary to fungal infections, actinomycosis, and nocardiosis. Pleural Disease. 4th ed., Vol. 11. Baltimore: Williams and Wilkins; 2001. p. 196-203.  Back to cited text no. 6
    
7.
Herring M, Pecora D. Pleural aspergillosis: A case report. Am Surg 1976;42:300-2.  Back to cited text no. 7
    
8.
Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC. Fungal empyema thoracis: An emerging clinical entity. Chest 2000;117:1672-8.  Back to cited text no. 8
    
9.
Tardieu P, Dieudonne P, Monod O, Atchoarena JB. Pleural aspergilloma. J Fr Med Chir Thorac 1964;18:591-6.  Back to cited text no. 9
    
10.
Krakówka P, Rowińska E, Halweg H. Infection of the pleura by Aspergillus fumigatus. Thorax 1970;25:245-53.  Back to cited text no. 10
    
11.
Herbrecht R, Denning DW, Patterson TF, Bennett JE, Greene RE, Oestmann JW, et al. Voriconazole vs. amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med 2002;347:408-15.  Back to cited text no. 11
    
12.
Stern JB, Girard P, Caliandro R. Pleural diffusion of voriconazole in a patient with aspergillus fumigatus empyema thoracis. Antimicrob Agents Chemother 2004;48:1065.  Back to cited text no. 12
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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