Letter to the Editor
Bronchial stump aspergillosis. An unusual disease
Aspergilosis del muñón bronquial. Una entidad inusual
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An unusual disease" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "330" "paginaFinal" => "331" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Elena Briz, Rolf Sander, Carlos Gómez González, Luis Borderías" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Elena" "apellidos" => "Briz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Rolf" "apellidos" => "Sander" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Carlos" "apellidos" => "Gómez González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "Luis" "apellidos" => "Borderías" "email" => array:1 [ 0 => "lborderiasc@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Sección de Neumología, Hospital San Jorge, Huesca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sección Geriatría, Hospital Sagrado Corazón de Jesús, Huesca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sección de Anatomía Patológica, Hospital General San Jorge, Huesca, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aspergilosis del muñón bronquial. Una entidad inusual" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Aspergillus</span> can cause a wide range of respiratory diseases depending on the fungus-host interaction, where the immune status of the subject plays an important role.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In very few cases have we seen an initially saprophytic case of patients after a lung resection, that affects the tissue granulation in the area of the suture and is called bronchial stump aspergillosis. Symptoms consist of coughing with mucous expectoration, sometimes haemoptysis, and dyspnea,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–5</span></a> and the differential diagnosis includes, among others, lung tumours, and other processes caused by <span class="elsevierStyleItalic">Aspergillus</span>.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6–10</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 61-year-old woman with no toxic habits and a history of right pneumonectomy after suffering a car accident in 1978. She was referred because of paroxysms of coughing and low mucous expectoration, general malaise, and dyspnoea which she related to her cough lasting approximately 8 weeks. These symptoms did not improve after administration of oral corticosteroids, bronchodilators, oral N-acetylcysteine and antibiotics. On examination there were no abnormalities except decreased a vesicular breath sound in the right chest, and the tests showed an ESR of 60<span class="elsevierStyleHsp" style=""></span>mmHg in the first hour, a concentration of IgE serum of 756<span class="elsevierStyleHsp" style=""></span>KU/l, <span class="elsevierStyleItalic">Aspergillus</span> IgE RAST 3.50<span class="elsevierStyleHsp" style=""></span>KU/l and an undetectable determination of <span class="elsevierStyleItalic">Aspergillus</span> precipitins. The other usual analytical tests, including other immunoglobulins, IgG and immunity subfractions, were normal. Chest radiograph and CT showed the sequelae of pneumonectomy, but there were no images of bronchiectasis, cavities or blisters, mucus plugs or atelectasis. The skin prick test for <span class="elsevierStyleItalic">Aspergillus</span> was negative and the spirometry ruled out bronchial obstruction.</p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Aspergillus fumigatus</span> grew in sputum studies (with CMI voriconazole at 0.5<span class="elsevierStyleHsp" style=""></span>μg/ml) and the sputum cytology showed signs of acute inflammation without eosinophils or neoplastic cells. The fibrobronchoscopy showed a necrotic mass that had a spherical morphology and seemed pearl shaped in the bronchial stump that was aspirated, and the underlying mucosa showed mild inflammation, without evidence of bleeding or other alterations. A histological examination and culture confirmed the presence of <span class="elsevierStyleItalic">Aspergillus.</span> The patient rejected an endoscopic removal of the suture and treatment with antifungals.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Followed in outpatients, the patient has remained asymptomatic and sputum tests have not been able to again isolate <span class="elsevierStyleItalic">Aspergillus</span> nor detect the presence of eosinophils in sputum and/or peripheral blood. The IgE RAST was normalised at 5 months (<0.35<span class="elsevierStyleHsp" style=""></span>KU/l), without modification to date, the total IgE has decreased (255<span class="elsevierStyleHsp" style=""></span>KU/l) and <span class="elsevierStyleItalic">Aspergillus</span> IgG precipitins have increased (126<span class="elsevierStyleHsp" style=""></span>mg/l), with negative skin tests persisting.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Aspergillosis of the bronchial stump is uncommon, and although it has been described with metallic suture materials and nylon,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> it more frequently occurs with the use of silk, as it did in this patient, because of their high capillarity and plurifilamentous nature, which triggers a local inflammatory process and encourages the colonisation of <span class="elsevierStyleItalic">Aspergillus</span>.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Most patients are immunocompetent and the latency period is variable; in this patient it was 32 years, which is the highest reported in the literature.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the few cases where serological tests are conducted they have been described as negative.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> In this case there was no asthma or eosinophilic inflammation, the skin prick test was negative, the values of IgE RAST, usually lower than those found in asthma or ABPA, and spirometry and monitoring of the peak expiratory flow showed no fall in FEV<span class="elsevierStyleInf">1</span> and PEF. At follow-up, IgE RAST figures were normalised, raising the number of precipitin, which shows a modification of the immune response after removal of aspergilloma from the stump, without any other clinical form such as mycetoma, asthma or pneumonitis by hypersensitivity coexisting.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The treatment of choice is the removal of the suture material by endoscopy, and if this is not possible or symptoms persist, treatment with sensitive antifungals such as voriconazole should be initiated.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a> The patient rejected both treatments. Unlike the rest of the reported cases, simply removing the aspergillosis necrotic mass was sufficient, and 5 years later the patient remains asymptomatic. This fact may have influenced the reason why the pneumonectomy was conducted as, unlike the other patients in the literature, it was due to a trauma and not tuberculosis or bronchopulmonary neoplasia. This treatment has not proven effective in other cases, relapses may occur,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> so that the patient has been indicated that at the onset of cough, haemoptysis, or dyspnoea a possible relapse should be ruled out. Despite its infrequency, this process should be considered when presented with patients with lung resections and persistent cough and/or chronic or self-limiting haemoptysis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Briz E, Sander R, Gómez González C, Borderías L. Aspergilosis del muñón bronquial. Una entidad inusual. Med Clin (Barc). 2016;146:330–331.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary aspergillosis: a clinical review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Kousha" 1 => "R. Tadi" 2 => "A.O. 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