Ann Thorac Surg 2000;70:302-304
© 2000 The Society of Thoracic Surgeons
Case report
Bronchial stump aspergillosis
Jean Philippe Le Rochais, MDa,
Philippe Icard, MDa,
Thierry Simon, MDa,
Philippe Poirier, MDa,
Claude Evrard, MDa
a Service de Chirurgie Thoracique et Cardiovasculaire, CHU Côte de Nacre, Caen, France
Address reprint requests to Dr Icard, Service de Chirurgie Thoracique et Cardiovasculaire, CHU Côte de Nacre, 14033 Caen, France
e-mail: icard-p{at}chu-caen.fr
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Abstract
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Two cases of bronchial stump aspergillosis were diagnosed 5 and 6 years after pneumonectomy for lung cancer. In each case, the fungal mass was endoscopically removed using standard forceps. A recurrence of the fungal mass persisted until all visible protruding nylon threads in the airway lumen were destroyed with a Nd:YAG laser. Removal of the visible suture is necessary for eliminating the infection. No additional local or systemic antifungal therapy is needed.
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Introduction
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Bronchial stump aspergillosis (BSA) is a rare event. To the best of our knowledge, only 20 cases have been reported previously, 13 of them in the English language [1–3]. We report two additional cases.
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Case reports
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Patient 1
A 47-year-old man with a history of ethylism and chronic bronchitis underwent a right pneumonectomy in April 1978 for a T2N0 epidermoid carcinoma. The postoperative course was uneventful. Five years later, systematic fiberoptic bronchoscopic examination revealed a granulation mass on the stump, with visible nylon sutures. The mass was removed entirely with forceps. Histologic examination showed that the mass contained abundant hyphae and fungal spores without cancer recurrence. Bacteriologic cultures identified Aspergillus fumigatus. Serodiagnosis was negative. Daily treatment with inhalation of amphotericin B (3 mg/day) was administered for 1 month. Five months later, fiberoptic bronchoscopic examination showed a recurrence of the fungal mass. The necrotic mass was removed completely, as was all visible part of the suture, which was eliminated with a Nd:YAG laser. No recurrence was observed at 6 months and 5 years of follow-up. The patient died in 1989 of small cell lung carcinoma with metastases.
Patient 2
A 56-year-old woman without any significant medical history underwent a right pneumonectomy in October 1982 for a T2N1 epidermoid carcinoma. Postoperative recovery was uneventful. Six years later, the patient suffered from acute dyspnea. Fiberoptic bronchoscopic examination revealed a fungal mass at the bronchial stump, 5 cm in diameter, surrounding the visible nylon sutures. The tumor partly obstructed the origin of the right bronchus. It was completely removed endoscopically with standard forceps. Histologic examination revealed a fungal ball with A fumigatus on culture. Serodiagnosis was negative. Inhalation of amphotericin B was administered for 6 weeks. Despite this treatment, two local recurrences of the fungal ball at the stump occurred at 3-month and 6-month intervals and were removed endoscopically. After destruction of all visible nylon threads at the stump with a Nd:YAG laser, no recurrence was observed. The bronchial stump remained endoscopically normal at 6 years of follow-up.
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Comment
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BSA, ie, aspergillus infection of the bronchial granulation tissue surrounding endobronchial sutures after pulmonary resection, is a rare form of tracheobronchial aspergillosis. Such colonization of the endobronchial suture and infection of surrounding bronchial granulation tissue by aspergillus can cause coughing and hemoptysis [1–3]. It also can be asymptomatic and diagnosed incidentally (as in patient 1). In contrast, it may cause severe dyspnea when the fungal ball is large enough to obstruct the proximal airway (as in patient 2). Therefore, BSA should be considered in the differential diagnosis of hemoptysis, coughing, and dyspnea occurring up to several years after lung operation, although asymptomatic presentation is possible. Fiberoptic bronchoscopic examination revealed a hemorrhagic granulation or a mass tumor on the stump, around the visible suture. Biopsies typically show inflammatory and necrotic areas, with infiltration by abundant hyphae showing the morphologic features of aspergillus. Cultures are usually positive for A fumigatus.
Only 20 cases have been reported in the world literature: Sawasaki and associates [1] reported nine cases and quoted seven cases in the German literature, Noppen and colleagues [2] reported three cases, and Roig and coworkers reported one case. The majority of cases (eight of nine) reported by Sawasaki and associates [1] occurred within 1 year after lung operation (from 6 to 12 months). The other case occurred 3 years and 2 months after operation. In contrast to the cases reported by Sawasaki and associates [1], our two cases, like those of Noppen and colleagues [2] and Roig and coworkers [3], occurred from 4 to 7 years after operation.
Sawasaki and associates [1] noted an extremely high incidence (24.6%) of local inflammation around silk sutures. However, these authors [1] reported only 5.7% of such bronchoscopic findings with nylon sutures. Silk suture was used widely by thoracic surgeons until the 1980s, and has been progressively replaced by nylon materials. The silk suture acts as a nidus for the aspergillus infection, and because of its high capillarity, favors the progression of infection. In contrast, the monofilament of nylon rarely provides such a nidus. In the report by Sawasaki and associates [1], the occurrence of BSA was 1.5% when silk was used as the endobronchial suture in pulmonary resection, whereas no BSA was encountered in 140 resections with nylon sutures. However, as shown in our two cases, BSA may occur with nylon sutures. To our knowledge, no case of BSA has been reported after the use of stainless steel bronchial sutures.
Although in most published cases BSA was isolated, simultaneous lung aspergilloma can be present, as in one case published by Noppen and colleagues [2]. BSA can also cause aspergillus empyema as reported by Parry and associates [4].
Our two cases of BSA show that sole removal of the fungal mass will not cure the infection completely. The elimination of all visible suture is necessary to avoid recurrence. Endobronchial sutures can be removed by means of a flexible bronchoscope, using standard or alligator forceps, and endoscopic suture scissors or Nd:YAG laser. If removal of the bronchial suture threads is not feasible or is refused by the patient, oral itraconazole can be a valid alternative treatment, as has been reported in three cases by Noppen and colleagues [2]. In our experience, inhalation of amphotericin B is not effective in preventing recurrence if the protruding thread remains in place.
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References
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Sawasaki H., Horie K., Yamada M., et al. Bronchial stump aspergillosis. J Thorac Cardiovasc Surg 1969;58:198-208.[Medline]
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Noppen M., Claes I., Maillet B., Meysman M., Monsieur I., Vincken W. Three cases of bronchial stump aspergillosis. Eur Respir J 1995;8:477-480.[Abstract]
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Roig J., Ruiz J., Puig X., Carreres A., Morera J. Bronchial stump aspergillosis. Four years after lobectomy. Chest 1993;104:295-296.[Abstract/Free Full Text]
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Parry M.F., Coughlin F.R., Zambetti F.X. Aspergillus empyema. Chest 1982;81:768-770.[Abstract]
Accepted for publication December 26, 1999.
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Abstract
Introduction
