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CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 2  |  Page : 151-154

Mediastinal aspergillosis of an immunocompetent host


1 Department of Microbiology, NRI Medical College and General Hospital, Chinakakani, Guntur, Andhra Pradesh, India
2 Department of Radiology, NRI Medical College and General Hospital, Chinakakani, Guntur, Andhra Pradesh, India

Date of Web Publication5-Jul-2016

Correspondence Address:
Bindu Madhav Yenigalla
Department of Microbiology, NRI Medical College and General Hospital, Chinakakani, Mangalagiri (M), Guntur - 522 503, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.185455

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  Abstract 

Aspergillus species are well-known opportunistic pathogens that can cause different infections, and are commonly seen in immunocompromised hosts. Invasive aspergillosis in an immunocompetent patient with extension to the mediastinum has been reported rarely. We report a case of a young male patient who had a huge mass lesion that is seen at the right side of mediastinum at lower paratracheal region, extending up to the hilum and pretracheal location. It was primarily diagnosed as pericardial cyst/right ventricular thrombus. The patient was diagnosed with aspergillosis caused by Aspergillus flavus by histopathology, staining, and fungal culture. The patient was treated with voriconazole and he was discharged after clearly advising the need for therapy. The patient did not come for the follow-up checkup and later when communicated, we came to knew that the patient had expired due to breathlessness.

Keywords: Antifungal therapy, Aspergillus flavus, immunopathogenesis, mediastinum


How to cite this article:
Yenigalla BM, Yarlagadda P, Myneni RB, Danaboyina AR. Mediastinal aspergillosis of an immunocompetent host. J NTR Univ Health Sci 2016;5:151-4

How to cite this URL:
Yenigalla BM, Yarlagadda P, Myneni RB, Danaboyina AR. Mediastinal aspergillosis of an immunocompetent host. J NTR Univ Health Sci [serial online] 2016 [cited 2020 Apr 9];5:151-4. Available from: http://www.jdrntruhs.org/text.asp?2016/5/2/151/185455


  Introduction Top


Aspergillus species are well-known opportunistic pathogens that can cause different infections, and are commonly seen in the immunocompromised hosts. Invasive aspergillosis is a serious complication in the immunocompromised patients. It is an opportunistic disease, which predominantly occurs in the lungs, although dissemination to virtually any organ is possible. Invasive aspergillosis in an immunocompetent patient with extension to the mediastinum has been reported rarely. [1] A key concept in immune responses to Aspergillus species is that host susceptibility determines the morphological form, antigenic structure, and physical location of the fungus. [2] The most common species isolated being Aspergillus fumigatus followed by Aspergillus flavus, Aspergillus niger, Aspergillus terreus. [3] Here we present a case of a young male patient who had presented with chest pain for almost 2 years that was finally diagnosed as aspergillosis of the mediastinum caused by A. flavus. The case becomes interesting that even after the initiation of the right therapy with voriconazole, the patient died of breathlessness.


  Case report Top


A 31-year-old male patient attended the Cardiology Outpatient Department with complaints of on-and-off retrosternal chest pain since 2 days. The patient had past history of using painkillers and medications for the chest pain for the last two years. The patient is a smoker and alcoholic. He was neither a diabetic nor hypertensive. On physical examination, the patient's vitals were all normal.

The patient was tested negative for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and all his blood parameters from complete blood picture were normal suggesting that the patient was not immunocompromised.

On radiological investigations, chest x-ray revealed condensed masses around the hilar region [Figure 1]. Echocardiograph showed a large organized thrombus anterior to the right ventricle with signs of compression. Computed tomography (CT) pulmonary angiogram reported no evidence of thromboembolism, large nonenhancing mass lesion measuring 65 mm × 71 mm seen at right side of mediastinum at lower paratracheal region, extending up to the hilum and pretracheal location [Figure 2] and [Figure 3]. It was primarily diagnosed as pericardial cyst/right ventricular thrombus.

For pathological and microbiological investigations, the patient was subjected to an ultrasound-guided fine-needle aspiration cytology (FNAC) of the pericardial cyst and samples were sent to the Microbiology and Pathology Department for diagnosis. The microbiology investigations upon the KOH wet mount and Gram stain preparation revealed fungal hyphae that were septate and showed dichotomous branching. Pathology reports of the FNAC also revealed the presence of fungal hyphae in the smears. In order to confirm the etiology of the infection, a repeat specimen by ultrasound-guided aspiration was suggested. Repeat specimens were collected and the direct microscopy findings were correlated with the primary specimen findings, and the patient was diagnosed with probable fungal infection of the mediastinum.
Figure 1: Chest x-ray showing radioopaque extrapulmonary mass along the right lower paratracheal region

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Figure 2: CT scan showing large paratracheal mediastinal mass on the right side

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Figure 3: Contrast enhanced CT showing a well-defined nonenhancing lesion anterior to right ventricle probably a pericardialcyst

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A CT-guided aspiration of the condensed masses from the hilar region was also performed, and on direct microscopy it also revealed septate fungal hyphae with dichotomous branching. All the samples were processed for culture on Sabouraud's dextrose agar and were incubated at 30°C. The fungal growth obtained was identified as A. flavus. The culture was also sent to the National Culture Collection for Pathogenic Fungi, Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India, for confirmation of our identification. The isolate was confirmed by them as A. flavus, both phenotypically and genotypically.

The patient was treated with voriconazole 400 mg bis in die (BD) for 1 day followed by 200 mg BD for 10 days, and he was discharged after clearly advising the need for therapy. The patient came for a follow-up 7 days after the discharge, and he was advised to continue on the same regimen. The patient did not come for further checkups, and later it was communicated to us that the patient had expired due to breathlessness.


  Discussion Top


Aspergillus is known to cause pulmonary infections in case of immunocompromised hosts but to a very lesser extent. Most of the cases have been documented in immunocompetent hosts. Even though with the availability of newer diagnostic methods, the attempt to constrain and combat few infections still remains a challenge.

In the present case, the patient was diagnosed with Aspergillosis of mediastinum and was started on antifungal therapy with voriconazole but the patient died. As evident from the published literature, the outcome of the patients with aspergillosis confined to mediastinum, had been fatal even after initiation of antifungal therapy [Table 1]. [1],[4],[5],[6],[7] It depicts that the patients who had localized involvement of the disease had an improved outcome, [1],[6] but those who had the spread of the disease into the mediastinum had a fatal outcome. [4],[5],[7]
Table 1: Table Showing Salient Features of the Published Case Reports

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The reasons for the demise of the patient even after initiation of accurate therapy had put the medical fraternity in a dilemma. When considering aspergillosis of pulmonary origin, "the host's defensive capacity is defined by the sum of resistance and tolerance. Resistance displays the ability to limit fungal burden and elimination of the pathogen, and tolerance means the ability to limit host damage caused by immune response. The T helper cell (TH1) response is associated with increased production of inflammatory cytokines IFNγ, IL2 and IL12 and stimulation of antifungal effector cells. Alternatively, TH2 type responses are associated with suppression of antifungal effector cell activity, decreased production of IFNγ and increased concentrations of IL4 and IL10, which promote humoral responses to Aspergillus." [2]

In our opinion, the protocol to treat patients with aspergillosis should include hospitalization of the infected patients and administration of antifungal therapy with continuous monitoring of the vital parameters. This could help in decreasing the mortality of the patients suffering from aspergillosis by providing supportive care and administration of anti-inflammatory drugs, if required, in order to combat the inflammatory response elicited by the host toward the pathogen.

We are also of strong opinion that further research on the immunopathogenesis of aspergillosis involving the mediastinum is required, focusing on the squelae of the effects, which take place after the initiation of the antifungal therapy, such as the types of antigens being released and the immunological events that follow their release, the role of immune cells, the types of cytokines being produced and their role in the inflammatory process that would dictate the outcome of the therapy that is given to the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kumar J, Seith A, Kumar A, Madan K, Guleria R. Chest wall and mediastinal nodal aspergillosis in an immunocompetent host. Diagn Interv Radiol 2009;15:176-8.  Back to cited text no. 1
    
2.
Lass-Flörl C, Roilides E, Löffler J, Wilflingseder D, Romani L. Mini review: Host defence in invasive aspergillosis. Mycoses 2013;56:403-13.  Back to cited text no. 2
    
3.
Krishnan S, Manavathu EK, Chandrasekar PH. Aspergillus flavus: An emerging non-fumigatus Aspergillus species of significance. Mycoses 2009;52:206-22.  Back to cited text no. 3
    
4.
Parameswaran K, Joshi M, Ravindran P. Unusual radiological presentation and rapid fatal progression of invasive pulmonary aspergillosis in an immunocompetent young patient. Respirology 1999;4:287-90.  Back to cited text no. 4
    
5.
Taouli B, Cadi M, Leblond V, Grenier PA. Invasive aspergillosis of the mediastinum and left hilum: CT features. AJR Am J Roentgenol 2004;183:1224-6.  Back to cited text no. 5
    
6.
Gupta S, Kakar A, Byotra SP, Prakash V. Invasive aspergillosis in an immunocompetent host. JK Science 2004;6:103-5.  Back to cited text no. 6
    
7.
Shakoor MT, Ayub S, Ayub Z, Mahmood F. Fulminant invasive aspergillosis of the mediastinum in an immunocompetent host: A case report. J Med Case Rep 2012;6:311.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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