Pediatr Radiol (1992) 22:601-602
Pediatric Radiology 9 Springer-Verlag 1992
Invasive pulmonary aspergillosis with pneumopericardium and pneumothorax A. Serrano-Gonzalez, J. M.Merino-Arribas, M.J. Ruiz-Lopez, J. Casado-Flores Pediatric Intensive Care Unit, Hospital del Nifio Jesfis, Autonoma University of Madrid, Avda. Menendez Pelayo, 65, E-28009 Madrid, Spain Received: 1 July 1992; accepted: 25 July 1992
Abstract. A case of an invasive pulmonary aspergillosis with p n e u m o p e r i c a r dium and p n e u m o t h o r a x in an immunoc o m p r o m i s e d child of 5 years is reported. H e was t r e a t e d with thoracic drainage, amphotericin B and itraconazole. T h e course was satisfactory.
dium. Chest CT showed a cavity in the right lower lobe with a mycetoma (Fig. 3). Two days later, another cavitary image showed up in the left upper lobe on the chest roentgenogram.
Invasive p u l m o n a r y aspergillosis appears almost exclusively in immunodepressed patients; the association with p n e u m o p e r i c a r d i u m is very infrequent and in these cases the o u t c o m e is usually fatal.
Bronchopulmonary lavage was negative for mycelia. The antiaspergillus antibodies (preceptin test and ELISA) were strongly positive. Aspergillus fumigatus grew on the culture plates placed in the patient's room and in the air-conditioningconduits. When the cavitary lesions were seen, the dose of amPhotericin B was increased to 1.5 mg/kg per day (12days later it was lowered to 0.8 mg/kg per day due to tubular damage) and 5-fluorocytosine was added (150 mg/kg per day). On day 11 itraconazole was added (3 mg/kg per day in a single dose that was increased to 5 mg/kg per day in two doses 5 days later). The course was satisfactory: clinical improvement was seen 15 days later and radiological ameloriation was seen 26 days later.
Case report A 5-year-old male was diagnosed as having acute lymphoblasticleukemia (ALL) type L2 and treated. After a good initial remission a haematological relapse occurred which was treated with protocol BMF-90. When the chemotherapeutic cycle ended and coinciding with an intense neutropenia, he presented fever and bronchopneumonia; despite the antibiotic treatment, the course was insidious, so amphotericin B treatment was instituted (0.8 mg/kg per day), with improvement, although the fever persisted. Three weeks after the fever had appeared, the patient came down with respiratory distress and hypoventilation in both pulmonary bases. The chest roentgenogram showed bilateral diffuse infiltrates, an image of cavitation in the right lower lobe and a great pneumopericardium (Fig. 1). Because there was neither tamponade nor respiratory failure, he was treated in a conservative fashion. Hours later, the patient suddenly worsened, presenting severe distress; chest radiography displayed a right tension pneumothorax (Fig.2); a thoracic drainage was inserted, which resolved the pneumothorax and the pneumopericar-
Correspondence to: Dr. A. Serrano-Gonzalez
Discussion
Fig. 1. Patchy areas ofconsolidation are present in both lungs. There is a cavity with intracavitary masses in the right lower lobe and pneumopericardium Fig.2. Chest radiograph shows right tension pneumothorax, pneumopericardium and cavitating lesion in the right lower lobe Fig.3. CT shows a cavitating lesion containing a nodule fungus ball
Invasive p u l m o n a r y aspergillosis has b e e n described in i m m u n o d e p r e s s e d patients with neutropenia, treated with wide-spectrum antibiotics and corticosteroids [1]. D u e to the advances in the t r e a t m e n t of leukemic patients, an increase in the survival of these patients has been achieved, and a greater risk of fungal infections has followed [2]. The most frequent presenting clinical picture is cough and fever of an insidious course [1]. Radiologically, it can present as a cavitating p u l m o n a r y disease or as diffuse infiltrates. In our case we found bilateral infiltrates and two cavitary lesions in the right lower and left u p p e r lobe. T h e a p p e a r a n c e of a p n e u m o p e r i c a r dium is a v e r y infrequent complication [3]; when it is very large or produces a cardiac t a m p o n a d e , d e c o m p r e s i o n with drainage is n e e d e d [4]. In our case, although it was large it did not produce any
602 symptoms until a tension p n e u m o t h o r a x was a d d e d 12 h later. The p n e u m o p e r i c a r d i u m could have been caused by fistulization of a pulmonary inflammatory process (in our case, a cavitating fungal infection) to the pericardial cavity [3]. The p n e u m o t h o r a x can be explained by either of two mechanisms: (1) direct communication of the pericardial space and the pleural space around the hiliar b l o o d vessels (pulm o n a r y artery or veins); or (2) fistulization of the m y c e t o m a into the pleural space [5]. In either, drainage of the pleural space can resolve the p n e u m o -
Announcements February 14-21,1993 - Acapulco, Mexico 22nd Annual Pediatric Postgraduate Course, Pediatric Update 1993 Sponsored by:Schneider Children's Hospital of Long Island Jewish Medical Center New Hyde Park, New York 11042, The Long Island Campus for the Albert Einstein College of Medicine. Program Chairmen: Philip Lanzkowsky, Schneider Children's Hospital of LIJ and I.Ronald Shenker, Schneider Children's Hospital of LIJ. This program will provide pediatricians, family physicians, nurse practitioners and allied health professionals with an understanding of: newer immunizations and antibiotic usage, newer diseases and their complications, behavioral issues in pediatric patients, adolescents engaged in high-risk behaviors, advances in congenital heart disease, newer
pericardium, as was the case in our patient. Although we instituted treatment with amphotericin B and 5-fluorocytosine, the patient did not improve, so we a d d e d a new antimycotic agent, itraconazole, which has been used in patients with invasive aspergillosis. References
1. Denning DW, Follansbee SE, Scolaro M, Norris S, Edelstein H, Stevens D (1991) Pulmonary aspergillosis in the acquired immunodeficiency syndrome. N Engl J Med 324:654-662
radiologic procedures for pediatric diagnosis, prevention of orthopaedic deformity in the developing infant and child, in an atmosphere conducive to concentrated learning while interacting informally with faculty and colleagues in a non-pressured setting. Accreditation: 22.75 credit hours in Category I of the ACCME. This program has been reviewed and is acceptable for 20 elective hours by the American Academy of Family Physicians. For further information: June Lewis, Office of Continuing Education, Long Island Jewish Medical Center, New Hyde Park, New York 11042. Phone: (718) 470-8650; Fax: (516) 3 52-4801 June 9-11, 1993 - London, UK European Society of Pediatric Radiology 30th Annual Congress The Annual Scientific Meeting of the Society will be held in London from the 9-11th June
2. Young R, Bennett J, Vogel C, Carbone R De Vita V (1970) Aspergillosis: the spectrum of the disease in 98 patients. Medicine 99:14%173 3. Miiller NL, Miller RR, Ostrow DN, Nelems B, Vickars LM (1987) Tension pneumopericardium: an unusual manifestation of invasive pulmonary aspergillosis. A JR 148:678-680 4. Luce JM, Ostenson RC, Springmeyer SC, Hudson LD (1979) Invasive aspergillosis presenting as pericarditis and cardiac tamponade. Chest 76:703-705 5. Albelda SM, Gefter WB,Epstein DM, Miller WT (1982) Bronchopleural fistula complicating invasive pulmonary aspergillosis. Am Rev Respir Dis 126:163-165
1993. The annual teaching and postgraduate course in paediatric radiology will precede the Congress on the 7th and 8th June 1993. The venue for both events will be the Queen Elizabeth II Conference Centre, London. For further information please contact." Congress Secretariat, Conference Associates and Services Ltd, ESPR, 55 New Cavendish Street, London W l M 7RE, UK October 12-14, 1993 - Lugano, Switzerland The Impact of MRI upon the Health System - An International Conference to Develop and Introduce Recommendations for the Appropriate Use of M i l l Deadline for registration: 1 September 1993;
afterwards on site only. For further information please contact. European Magnetic Resonance Forum Foundation, RO.Box 1235, CH-6684 Minusio-Locarno, Switzerland. Fax: + 41-93-67 6295.
Pediatric Radiology 9 Springer-Verlag 1992
Invasive pulmonary aspergillosis with pneumopericardium and pneumothorax A. Serrano-Gonzalez, J. M.Merino-Arribas, M.J. Ruiz-Lopez, J. Casado-Flores Pediatric Intensive Care Unit, Hospital del Nifio Jesfis, Autonoma University of Madrid, Avda. Menendez Pelayo, 65, E-28009 Madrid, Spain Received: 1 July 1992; accepted: 25 July 1992
Abstract. A case of an invasive pulmonary aspergillosis with p n e u m o p e r i c a r dium and p n e u m o t h o r a x in an immunoc o m p r o m i s e d child of 5 years is reported. H e was t r e a t e d with thoracic drainage, amphotericin B and itraconazole. T h e course was satisfactory.
dium. Chest CT showed a cavity in the right lower lobe with a mycetoma (Fig. 3). Two days later, another cavitary image showed up in the left upper lobe on the chest roentgenogram.
Invasive p u l m o n a r y aspergillosis appears almost exclusively in immunodepressed patients; the association with p n e u m o p e r i c a r d i u m is very infrequent and in these cases the o u t c o m e is usually fatal.
Bronchopulmonary lavage was negative for mycelia. The antiaspergillus antibodies (preceptin test and ELISA) were strongly positive. Aspergillus fumigatus grew on the culture plates placed in the patient's room and in the air-conditioningconduits. When the cavitary lesions were seen, the dose of amPhotericin B was increased to 1.5 mg/kg per day (12days later it was lowered to 0.8 mg/kg per day due to tubular damage) and 5-fluorocytosine was added (150 mg/kg per day). On day 11 itraconazole was added (3 mg/kg per day in a single dose that was increased to 5 mg/kg per day in two doses 5 days later). The course was satisfactory: clinical improvement was seen 15 days later and radiological ameloriation was seen 26 days later.
Case report A 5-year-old male was diagnosed as having acute lymphoblasticleukemia (ALL) type L2 and treated. After a good initial remission a haematological relapse occurred which was treated with protocol BMF-90. When the chemotherapeutic cycle ended and coinciding with an intense neutropenia, he presented fever and bronchopneumonia; despite the antibiotic treatment, the course was insidious, so amphotericin B treatment was instituted (0.8 mg/kg per day), with improvement, although the fever persisted. Three weeks after the fever had appeared, the patient came down with respiratory distress and hypoventilation in both pulmonary bases. The chest roentgenogram showed bilateral diffuse infiltrates, an image of cavitation in the right lower lobe and a great pneumopericardium (Fig. 1). Because there was neither tamponade nor respiratory failure, he was treated in a conservative fashion. Hours later, the patient suddenly worsened, presenting severe distress; chest radiography displayed a right tension pneumothorax (Fig.2); a thoracic drainage was inserted, which resolved the pneumothorax and the pneumopericar-
Correspondence to: Dr. A. Serrano-Gonzalez
Discussion
Fig. 1. Patchy areas ofconsolidation are present in both lungs. There is a cavity with intracavitary masses in the right lower lobe and pneumopericardium Fig.2. Chest radiograph shows right tension pneumothorax, pneumopericardium and cavitating lesion in the right lower lobe Fig.3. CT shows a cavitating lesion containing a nodule fungus ball
Invasive p u l m o n a r y aspergillosis has b e e n described in i m m u n o d e p r e s s e d patients with neutropenia, treated with wide-spectrum antibiotics and corticosteroids [1]. D u e to the advances in the t r e a t m e n t of leukemic patients, an increase in the survival of these patients has been achieved, and a greater risk of fungal infections has followed [2]. The most frequent presenting clinical picture is cough and fever of an insidious course [1]. Radiologically, it can present as a cavitating p u l m o n a r y disease or as diffuse infiltrates. In our case we found bilateral infiltrates and two cavitary lesions in the right lower and left u p p e r lobe. T h e a p p e a r a n c e of a p n e u m o p e r i c a r dium is a v e r y infrequent complication [3]; when it is very large or produces a cardiac t a m p o n a d e , d e c o m p r e s i o n with drainage is n e e d e d [4]. In our case, although it was large it did not produce any
602 symptoms until a tension p n e u m o t h o r a x was a d d e d 12 h later. The p n e u m o p e r i c a r d i u m could have been caused by fistulization of a pulmonary inflammatory process (in our case, a cavitating fungal infection) to the pericardial cavity [3]. The p n e u m o t h o r a x can be explained by either of two mechanisms: (1) direct communication of the pericardial space and the pleural space around the hiliar b l o o d vessels (pulm o n a r y artery or veins); or (2) fistulization of the m y c e t o m a into the pleural space [5]. In either, drainage of the pleural space can resolve the p n e u m o -
Announcements February 14-21,1993 - Acapulco, Mexico 22nd Annual Pediatric Postgraduate Course, Pediatric Update 1993 Sponsored by:Schneider Children's Hospital of Long Island Jewish Medical Center New Hyde Park, New York 11042, The Long Island Campus for the Albert Einstein College of Medicine. Program Chairmen: Philip Lanzkowsky, Schneider Children's Hospital of LIJ and I.Ronald Shenker, Schneider Children's Hospital of LIJ. This program will provide pediatricians, family physicians, nurse practitioners and allied health professionals with an understanding of: newer immunizations and antibiotic usage, newer diseases and their complications, behavioral issues in pediatric patients, adolescents engaged in high-risk behaviors, advances in congenital heart disease, newer
pericardium, as was the case in our patient. Although we instituted treatment with amphotericin B and 5-fluorocytosine, the patient did not improve, so we a d d e d a new antimycotic agent, itraconazole, which has been used in patients with invasive aspergillosis. References
1. Denning DW, Follansbee SE, Scolaro M, Norris S, Edelstein H, Stevens D (1991) Pulmonary aspergillosis in the acquired immunodeficiency syndrome. N Engl J Med 324:654-662
radiologic procedures for pediatric diagnosis, prevention of orthopaedic deformity in the developing infant and child, in an atmosphere conducive to concentrated learning while interacting informally with faculty and colleagues in a non-pressured setting. Accreditation: 22.75 credit hours in Category I of the ACCME. This program has been reviewed and is acceptable for 20 elective hours by the American Academy of Family Physicians. For further information: June Lewis, Office of Continuing Education, Long Island Jewish Medical Center, New Hyde Park, New York 11042. Phone: (718) 470-8650; Fax: (516) 3 52-4801 June 9-11, 1993 - London, UK European Society of Pediatric Radiology 30th Annual Congress The Annual Scientific Meeting of the Society will be held in London from the 9-11th June
2. Young R, Bennett J, Vogel C, Carbone R De Vita V (1970) Aspergillosis: the spectrum of the disease in 98 patients. Medicine 99:14%173 3. Miiller NL, Miller RR, Ostrow DN, Nelems B, Vickars LM (1987) Tension pneumopericardium: an unusual manifestation of invasive pulmonary aspergillosis. A JR 148:678-680 4. Luce JM, Ostenson RC, Springmeyer SC, Hudson LD (1979) Invasive aspergillosis presenting as pericarditis and cardiac tamponade. Chest 76:703-705 5. Albelda SM, Gefter WB,Epstein DM, Miller WT (1982) Bronchopleural fistula complicating invasive pulmonary aspergillosis. Am Rev Respir Dis 126:163-165
1993. The annual teaching and postgraduate course in paediatric radiology will precede the Congress on the 7th and 8th June 1993. The venue for both events will be the Queen Elizabeth II Conference Centre, London. For further information please contact." Congress Secretariat, Conference Associates and Services Ltd, ESPR, 55 New Cavendish Street, London W l M 7RE, UK October 12-14, 1993 - Lugano, Switzerland The Impact of MRI upon the Health System - An International Conference to Develop and Introduce Recommendations for the Appropriate Use of M i l l Deadline for registration: 1 September 1993;
afterwards on site only. For further information please contact. European Magnetic Resonance Forum Foundation, RO.Box 1235, CH-6684 Minusio-Locarno, Switzerland. Fax: + 41-93-67 6295.
