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Direct transbronchial administration of liposomal amphotericin B into a pulmonary aspergilloma
Takayuki Takeda1, Hideki Itano2, Ryouhei Kakehashi3
1Division of Respiratory Medicine, Department of Internal Medicine, Uji Tokushukai Medical Center, 86, Kasuganomori, Ogura-cho, Uji City, Kyoto 611-0042, Japan.
Abstract:
Pulmonary aspergillomas usually occur in pre-existing lung cavities exhibiting local immunodeficiency. As pulmonary aspergillomas only partially touch the walls of the cavities containing them, they rarely come into contact with the bloodstream, which makes it difficult for antifungal agents to reach them. Although surgical treatment is the optimal strategy for curing the condition, most patients also have pulmonary complications such as tuberculosis and pulmonary fibrosis, which makes this strategy difficult. A 72-year-old male patient complained of recurrent hemoptysis and dyspnea, and a chest X-ray and CT scan demonstrated the existence of a fungus ball in a pulmonary cavity exhibiting fibrosis. Although an examination of the patient's sputum was inconclusive, his increased 1-3-beta-D-glucan level and Aspergillus galactomannan antigen index were suggestive of pulmonary aspergilloma. Since the systemic administration of voriconazole for two months followed by itraconazole for one month was ineffective and surgical treatment was not possible due to the patient's poor respiratory function, liposomal amphotericin B was transbronchially administered directly into the aspergilloma. The patient underwent fiberoptic bronchoscopy, and a yellow fungus ball was observed in the cavity connecting to the right B(2)bi-beta, a biopsy sample of which was found to contain Aspergillus fumigatus. Nine transbronchial administrations of liposomal amphotericin B were conducted using a transbronchial aspiration cytology needle, which resulted in the aspergilloma disappearing by seven and a half months after the first treatment. This strategy could be suitable for aspergilloma patients with complications because it is safe and rarely causes further complications.
Insights
Transbronchial administration of liposomal amphotericin B offers a safe and effective treatment for pulmonary aspergilloma, especially in patients with complications unsuitable for surgery. This method successfully eliminated the fungus ball in a case study.
Area of Science:
- Pulmonology
- Mycology
- Interventional Pulmonology
Background:
- Pulmonary aspergillomas form in lung cavities with local immunodeficiency, posing treatment challenges due to poor drug penetration.
- Surgical resection is optimal but often precluded by comorbidities like tuberculosis and pulmonary fibrosis common in affected patients.
- Systemic antifungal therapy can be ineffective, necessitating alternative treatment strategies for pulmonary aspergilloma.
Purpose of the Study:
- To evaluate the efficacy and safety of transbronchial administration of liposomal amphotericin B for treating pulmonary aspergilloma.
- To present a minimally invasive therapeutic option for patients with pulmonary aspergilloma and significant complications.
Main Methods:
- A 72-year-old male with recurrent hemoptysis and dyspnea underwent diagnosis of pulmonary aspergilloma via imaging and biomarkers.
- After failure of systemic voriconazole and itraconazole, and deeming surgery impossible due to poor respiratory function, liposomal amphotericin B was administered transbronchially.
- Nine administrations were performed directly into the aspergilloma using a transbronchial aspiration cytology needle guided by fiberoptic bronchoscopy.
Main Results:
- Fiberoptic bronchoscopy confirmed Aspergillus fumigatus in the fungus ball within the pulmonary cavity.
- Transbronchial liposomal amphotericin B administration led to the complete disappearance of the aspergilloma over seven and a half months.
- The treatment was well-tolerated, with no significant complications reported, indicating a favorable safety profile.
Conclusions:
- Transbronchial liposomal amphotericin B administration is a viable and safe alternative treatment for pulmonary aspergilloma.
- This approach is particularly suitable for patients with pulmonary complications who are not candidates for surgical intervention.
- Direct instillation of antifungal agents may overcome the challenges of systemic drug delivery in pulmonary aspergilloma.
