Case report 2: Fungal infections in chronic obstructive pulmonary disease

This is a case report of fungal infection in a patient with known chronic obstructive pulmonary disease (COPD) as a result of smoking. The 45-year-old Belgian male teacher with a smoking history of 30 pack years and stage III COPD was receiving home treatment of corticosteroids (methylprednisolone 4 mg, plus fluticasone inhaler) and an antimuscarinic (atropine inhaler). The patient presented with a pulmonary lesion in the right upper lobe, and a lobectomy was performed. Histology revealed a 2-cm cavity with necrotic contents, as well as pleural and parenchymal fibrosis. Cultures were negative for fungi. Over the following 2 years, the patient was treated twice with a short course of systemic steroids and was never re-admitted to the hospital with an exacerbation. Over the period of 2–4 years after presentation of lesion and lobectomy, the patient began to show intermittent haemoptysis with mild fatigue and some weight loss. However, there was no fever and laboratory results showed only mild or absent inflammation over this period. The following year, the patient had exacerbation of COPD. He had accompanying respiratory failure, requiring mechanical ventilation, and was admitted to the intensive care unit (ICU). Computerised tomography scan (Fig. 1) showed signs of fibrosis and parenchymal consolidation in the right lung and mild infiltrates throughout both lungs. The presumed bacterial COPD exacerbation was treated with antibiotics (amoxicillin–clavulanate, 1 g, i.v., four times a day) and high-dose steroids (methylprednisolone, 40 mg, i.v., three times a day). Five days later, the patient s oxygen requirements had increased (FiO2 70%) and C-reactive protein (CRP) levels increased from 32 mg l (at the start of antibiotic therapy) to 233 mg l. Tracheal aspirate was positive for Pseudomonas species and the patient was therefore switched to meropenem (1 g, three times a day). FiO2 (45%) and CRP (65 mg l) indicated a positive response after 2 days treatment with meropenem. On the tenth day in the ICU, the patient developed sudden onset of fever, haemoptysis and CRP of 322 mg l, despite treatment with antibiotics. Diagnostic tests revealed a positive galactomannan test from broncho-alveolar lavage (BAL) [optical density (OD) 5] but not from serum (OD <0.1). No lesions were observed on bronchoscopy. However, 2 days later, cultures yielded Aspergillus fumigatus and hyphae were detected from fine needle aspiration and transbronchial biopsy. Treatment with intravenous voriconazole (6 mg kg twice a day on day 1, followed by 4 mg kg twice a day thereafter) was initiated and steroid treatment (methylprednisolone) was tapered to 20 mg. Diagnostic tests were carried out again after a week of antifungal therapy. Galactomannan in BAL fluid had improved (OD 1.2) and there was no evidence of Aspergillus species from BAL. The patient was then switched to oral therapy with voriconazole; 200 mg, twice daily (after 13 days of intravenous voriconazole). Improvement of the patient s symptoms continued and he was successfully weaned from the ventilator a week after switching to oral voriconazole. A few days later, the patient was discharged from the ICU, and after a total of 32 days antifungal therapy with voriconazole, the voriconazole was stopped and steroid dose was further tapered down to 4 mg a day. Repeated sputum cultures did not show any evidence of Aspergillus. After discharge from the hospital, the patient was followed up in the outpatient clinic. Chest X-ray showed one small cavity in the right upper lobe, and the patient had apical pachypleura. No further exacerbations occurred, and the patient was doing well on inhalers alone. Systemic steroids were avoided from thereon in, because of the patient s history of aspergillosis. Correspondence: Wouter Meersseman, Medical Intensive Care Unit, University Hospital Leuven, Herestraat 49, B-3000 Leuven, Belgium. Tel. : +32 16 340916. Fax: +32 16 344230. E-mail: wouter.meersseman@uz.kuleuven. ac.be