Thorax (1972), 27, 33.

Pulmonary aspergillosis caused byAspergillus flavus

E. S. MAHGOUB and A. M. EL HASSAN

Departments of Microbiology and Pathology, Faculty of Medicine, University of Khartoum

Bronchopulmonary aspergillosis is usually caused by Aspergillus fumigatus. The six cases fromthe Sudan reported here were due to Aspergillus flavus. Three of the patients had primaryinvasive disease, one had Aspergillus mycetoma in a pre-existing lung cavity, and two hadallergic aspergillosis. A special feature of the invasive disease was the clinical and radiographicsimulation of malignancy, particularly in one patient who had multiple disseminated nodules offungal granulomata in the skin of the lower abdomen.

Fungi of the genus Aspergillus are filamentousorganisms that produce airborne spores and havea wide distribution as saprophytes in nature.Occasionally they become pathogenic to man andcause a variety of lesions, the most important ofwhich is pulmonary disease. The latter appears inwell-recognized clinical forms for which severalclassifications have been suggested (Gowing andHamlin, 1960; Campbell and Clayton, 1964;Kennedy, Malone, and Blyth, 1970). Another type

of aspergillosis is that affecting the paranasalsinuses, a rare condition elsewhere but not uncom-mon in the Sudan (Sandison, Gentles, Davidson,and Milosev, 1967; Milosev, Mahgoub, Abdel A'al,and El Hassan, 1969).

This paper describes the clinical types of pul-monary aspergillosis in tke Sudan where, like theparanasal form, it is caused by Aspergillus flavusand not A. fumigatus, which is the commonerpathogen in many other parts of the world.

TABLEPULMONARY ASPERGILLOSIS: CLINICAL, RADIOGRAPHIC AND LABORATORY DATA

Case 1 2 3 4 5 6

Age (yr) 50 50 45 45 50 27Sex M M M M M FOccupation Farmer Merchant Farmer Engineer Farmer HousewifePresenting Cough, sputum Cough and breath- Cough Cough, sputum Cough, fever and Cough and breath-symptoms and haemoptysis. lessness. Skin and respiratory breathlessness for lessness; greenish

Loss of weight nodules over lower distress 2 mth. History of and sometimesabdomen. Loss of asthma 1 yr bloody sputum;weight fever

Radiography Opacity in left X-ray not Opacity in left Mottled appear- Mottled appear- Dense opacity atlower lobe sugges- available lower lobe ance all over lung ance all over lung both bases; moretive ofneoplasm fields fields near R. hilum.

Smaller opacitiesin R. subclavicularregion

Sputum culture jB-haemolytic Normal flora Normal flora C. albicans Pneumococcus A.flavusstreptococcus pneumoniae

Blood eosinophilia Normal Normal Normal Normal Normal High-1030/mm'Precipitins against + + + + + +A.flavusHistology Pulmonary fungal Skin fungal Aspergillus Not done Not done Not done

granuloma granuloma mycetomaTreatment Lobectomy Amphotericin B Excision offungal Amphotericin B Ephedrine and Tetracycline,

mass phenobarbitone aminophyline, andphenobarbitone

Outcome Alive and well Died Alive and well Died Died; anaphylactic Left hospital toshock after deliver at homepenicillin injection 2 yr ago-not seen

since

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E. S. Mahgoub and A. M. El Hassan

METHODS AND MATERIALS

This study includes six patients who were seen at theSha'ab Chest Hospital in Khartoum between 1968 and1971. The available clinical, radiographic, andlaboratory data are shown in the Table. Sputumspecimens were stained by the Ziehl-Neelsen methodand cultured for bacteria and fungi daily for sevendays. Blood agar, Lowenstein Jensen medium, andSabouraud's dextrose agar with chloramphenicol wereused. Total, differential white cell, and eosinophilcounts were done. The serum from each patient wastested by means of Ouchterlony agar-gel diffusion forprecipitins against four strains of A. flavus, A.fumigatus, A. terreus, A. nidulans, and A. niger. Anti-gens from these fungi were prepared by ultrasonicdisruption of a float culture in phosphate-bufferedsaline and precipitation with acetone (Mahgoub, 1971).Pathological studies were performed on the left lowerlobe from case 1, a subcutaneous nodule from case 2,and a resected pulmonary tumour from case 3.Paraffin sections of formalin-fixed tissue were stainedwith haematoxylin and eosin (H.E.), periodic acidSchiff (PAS), and methenamine silver. No culture wasmade from these tissues because all specimens weresubmitted in formalin.

RESULTS

The Table shows a summary of the clinical, radio-graphic, and laboratory data. All the patients but

FIG. 1. Case 5. Chest radiograph showing generalizedmottled appearance.

:. :

FIG. 2. Case 6. Chest radiograph showing dense opacitiesat both lung bases and hila, especialh' oni the right side.

one were males whose ages were either 45 or 50years. The single female was 27 years old. Three ofthe patients were farmers and patient 2 had been afarmer earlier in life. The major symptoms werecough and breathlessness. Haemoptysis occurredin only one patient. Radiographic examinationshowed either generalized mottling (Fig. 1) oropacities mainly at the lung bases (Fig. 2). Apartfrom their fungal infection these patients werehealthy adults with the exception of patient 3, whohad a pre-existing lung cavity. In particular, nopatient had evidence of paranasal aspergillosis andnone was on steroid or antibiotic therapy. Thediagnosis of aspergillosis was established by demon-stration -of precipitins against A. flavus antigens inall cases, coupled with the presence of fungalhyphae that looked like Aspergillus species inhistological sections from cases 1, 2, and 3; and apositive culture of A. flavus from the sputum incase 6.

SEROLOGY Precipitation arcs developed against A.flavuis in all cases. No precipitation lines wereseen with A. fumigatus, A. terreus, A. nidulans, orA. niger. These positive lines were sharp and morethan one line developed with all sera, as Fig. 3 fromcase 2 shows.

CULTURE Sputum from case 1 yielded a /3-haemno-lytic streptococcus and that from case 4 Candidaalbicans. From case 5 Pneumococcus pneumoniaewas isolated and A. flavus was grown from case 6.

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Pulmonary aspergillosis caused by Aspergillus flavus

2800./ is;

A..

A.T

A. N

FIG. 3. Case 2. Gel diffusionAspergillus antigens:

2070'2800 _A. flavus strains4839

4841A.F. A. fumigatusA.N. A. nidulansS Patient's serum.

plate of serum against

PATHOLOGY

CASE 1 (Fig. 4) Arising in the left lower lobebronchus was an irregular mass of yellowish whitetissue measuring 2-7 cm in its greatest diameter. It

FIG. 5. Section of the lower lobe bronchus showingmultiple granulomata adjacent to the bronchial gland.H.E. x73.

.1-.C 5 6 7 8 9 IC) . 12cm;

FIG. 4. The cut surface of the left lower lobe showing atumour-like lesion arising in the wall of the lower lobebronchus. Note bronchiectasis of branches to the apicalsegment.

was firm in consistency and the cut surface was ofa homogenous close texture. The lumen of the mainlower lobe bronchus was slightly narrowed and theoverlying mucosa was apparently intact. Thebronchial branches to the apical portion of the lobewere surrounded and stenosed by the mass at theirorigin, dilated distally, and they contained inspis-sated mucus. The rest of the lung showed patches ofearly bronchopneumonia. Histology of the mass

showed several granulomata scattered in a densehyaline fibrous tissue stroma. These granulomatawere composed of epithelioid and multinucleatedgiant cells and in the centre of some therewere small microabscesses (Fig. 5). The PAS andsilver stains showed septate fungal hyphae whichoccasionally branched laterally, inside the giantcells, and in the microabscesses (Fig. 6). Focal areasof fibrinoid necrosis but without related fungalelements and with peripheral palisading of histio-cytes were also seen. Some arteries showed aninflammatory reaction involving all coats composed

2070*I..I./

4841

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E. S. Mahgoub and A. M. El Hassan

FIG. 6. Fungal graniuloma showing a septate hypha insidea multinucleated giant cell. PAS x 365.

of lymphocytes, histiocytes, and neutrophils butfungal invasion of the vessel wall was not observed(Fig. 7). The inflammatory granulomatous reactioninvaded the bronchial cartilage and there weresmall mucosal ulcers.

CASE 2 The specimen received was an irregularmass of subcutaneous tissue measuring I cm in itsgreatest diameter. It was unencapsulated and firmin consistency and the cut surface was yellowishwhite and homogenous. Histopathology showed thesame features as in case 1 with the reaction involv-ing the dermis and subcutaneous tissues.

CASE 3 The surgically removed specimenmeasured 4 cm in its greatest diameter. It was of a

light brown colour and friable. Histopathologyshowed tangled fungal hyphae with septa andbranching. Some of these carried vesicles typical ofAspergillus species.

DISCUSSION

The commonest cause of bronchopulmonary asper-gillosis is A. fumigatus (Hinson, Moon, and

Ko.~~~~~~~~~~~~~~~~~~~~F* SEe e.?. 4> lftKW [9 jv

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r.C Ct < %>.0~~~~~~~~~~~~~~~~~~~~~~~~0

FG7.A tagntal cu,reytewl f hc hwacteancroicinlnlatryrecton HE xl180.

Plummer,1952;Campbell andC

one pain nyi u eisisraoa' or

species.~~~~WTh rcptntsti aryrlabl n h

digoiso'spriloiLogotonPps

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'FIG. 7. A tangentially cut artery, the wall of which showsacute and chronic inflanmmatory reaction. H.E. X 180.

Plummer, 1952; Campbell and Clayton, 1964;Landrigan, Wasty, and Nigam, 1968; Ikemoto,Watanabe, and Mor, 1971). Occasionally A. flavusis the causal organism (Finegold, Will, and Murray,1959; Naji, 1959; Carbone, Sabesin, Sidransky, andFrei, 1964). Although A. flavus was isolated fromone patient only in our series it is reasonable toassume that in all cases infection was due to thisfungus as sera from all patients reacted with A.flavus antigens and not with any other Aspergillusspecies. The precipitin test is fairly reliable in thediagnosis of aspergillosis (Longbottom and Pepys,1964; Walter and Jones, 1968). In cases of primaryparanasal aspergilloma reported from the Sudanby Milo'iev et al. (1969) A. flavus was also the solecausative organism. It seems that the role of A.fumigatus as a pathogen in other parts of the worldis performed by A. flavus in the Sudan.Three types of pulmonary aspergillosis are de-

monstrated in this series. Cases 1, 2, and 4 are of aprimary and invasive nature. There was no otherassociated disease. Isolation of C. albicans from thesputum of case 4 is of no significance because the

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Pulmonary aspergillosis caused by Aspergillus flavus

precipitation test against C. albicans was negativeand the agglutination test was of very low titre.Case 3 was a typical aspergillus mycetoma filling a

cavity which was probably tuberculous in nature.Cases 5 and 6 were examples of the allergic type ofaspergillosis. Patient 5 had a history of asthma andpatient 6 had wheezing sounds over the lungs anda very high eosinophil count.The clinical features of patients 1 and 2 sug-

gested a carcinoma of the bronchus; the patientspresented with cough, haemoptysis, and loss ofweight, and in addition patient 2 had multip'le skinnodules simulating metastases. Disseminated asper-

gillosis, with nodules in the skin, was reported pre-

viously by Vedder and Schorr (1969).It is almost certain that the bronchiectasis in case

1 was the effect rather than the cause of the fungalgranuloma; the patient had no history of antecedentrespiratory disease and the healthy looking butdilated bronchi did not show evidence of bacterialor fungal infection. We believe that the histopatho-logical changes in the first two cases are due to twofactors: first, the invasive nature of the fungus and,second, the associated immunological reactionwhich is suggested by the presence of fibrinoidnecrosis and arteritis. The role of fungal meta-bolites or toxin cannot be excluded.

We should like to acknowledge the help of Dr. A'bdinSharaf, Dr. Sir Abdel Magid, and Mr. Ahmed AbdelAziz of the Chest Hospital. Our thanks are alsoextended to Dr. Habib Abdalla, who reported the chestradiographs, and to Miss Christine Philpot, of theMycological Reference Laboratory, London School ofHygiene and Tropical Medicine for typing the manu-

script.

REFERENCESCampbell, M. J., and Clayton, Y. M. (1964). Bronchopul-

monary aspergillosis. Amer. Rev. resp. Dis., 89, 186.

Carbone, P. P., Sabesin, S. M., Sidransky, H., and Frei, E.(1964). Secondary aspergillosis. Ann. intern. Med., 60,556.

Finegold, S. M., Will, D., and Murray, J. F. (1959). Aspergil-losis; a review and report of 12 cases. Amer. J. Med., 27,463.

Gowing, N. F. C., and Hamlin, I. M. E. (1960). Tissuereactions to Aspergillus in cases of Hodgkin's diseaseand leukaemia. J. clin. Path., 13, 396.

Hinson, K. F. W., Moon, A. J., and Plummer, N. S. (1952).Broncho-pulmonary aspergillosis; a review and a reportof eight new cases. Thorax, 7, 317.

Ikemoto, H., Watanabe, K., and Mori, T. (1971). Pulmonaryaspergilloma. Sabouraudia, 9, 30.

Kennedy, W. P. U., Malone, D. N., and Blyth, W. (1970).Necrotizing pulmonary aspergillosis. Thorax, 25, 691.

Landrigan, P. L., Wasty, G., and Nigam, S. (1968). Pul-monary aspergillosis: report of seven cases. Canad.med. Ass. J., 98, 642.

Longbottom, J. L., and Pepys, J. (1964). Pulmonary asper-gillosis: diagnostic and immunological significance ofantigens and C-substance in Aspergillus fumigatus.J. Path. Bact., 88, 141

Mahgoub, E. S. (1971). Mycological and serological studieson Aspergillus flavus isolated from paranasal aspergil-loma in Sudan. J. trop. Med. Hyg., 74, 162.

Milosev, B., Mahgoub, E. S., Abdel A'al, O., and El Hassan,A. M. (1969). Primary aspergilloma of paranasal sinusesin the Sudan. Brit. J. Surg., 56, 132.

Naji, A. F. (1959). Bronchopulmonary aspergillosis; reportof two new cases, review of literature, and suggestionfor classification. Arch. Path., 68, 282.

Sandison, A. T., Gentles, J. C., Davidson, C. M., andMilosev, B. (1967). Aspergilloma of paranasal sinusesand orbit in Northern Sudanese. Sabouraudia, 6, 57.

Vedder, J. S., and Schorr, W. F. (1969). Primary disseminat-ed pulmonary aspergillosis with metastatic skin nodules.J. Amer. med. Ass., 209, 1191.

Walter, J. E., and Jones, R. D. (1968). Serologic tests indiagnosis of aspergillosis. Dis. Chest, 53, 729.

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