Salvage therapy with topical antifungal for Aspergillus fumigatus empyema complicating extrapleural pneumonectomy

Our plain-English summary of Salvage therapy with topical antifungal for Aspergillus fumigatus empyema complicating extrapleural pneumonectomy, by M. Purohit, A. Guleri, J. Zacharias (Interactive Cardiovascular and Thoracic Surgery, 2012).

The study

• Authors: M. Purohit, A. Guleri, J. Zacharias
• Journal: Interactive Cardiovascular and Thoracic Surgery
• Published: 2012;15(3):518-9
• Type of article: Case report
• Cited by: 9 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

We describe an unusual case of Aspergillus fumigatus empyema and bronchopleural fistulae after extrapleural pneumonectomy (EPP) and chemoradiotherapy (CRT), which was treated successfully under salvage conditions with debridement, an innovative topical antifungal application and supplemented systemic antifungal therapy and which went on for a definitive surgical procedure. Combinations of CRT and EPP have been recommended in a select group of patients with malignant mesothelioma. Irrespective of the combination, EPP is associated with mortality in the range of 4-15% and a complication rate as high as 62%.

In plain English

This case report described one patient, a 63-year-old man and former shipyard worker. He had a right extrapleural pneumonectomy for stage 1b malignant epithelioid mesothelioma, followed by chemotherapy and radiotherapy. Within 2 weeks of finishing that treatment he was admitted with a worsening cough. Imaging showed bronchopleural fistulae (abnormal openings between the airway and the chest cavity) and a fluid collection in the right chest cavity, and he was treated for empyema (infected fluid in the chest cavity). Swabs from the chest cavity grew the fungus Aspergillus fumigatus. Antifungal drugs given into a vein had a limited response. Doctors then mixed about 200 mg of amphotericin B into 4 gm of a gelatine powder called Spongostan and applied the mixture to the whole right chest cavity. This was followed by oral posaconazole for 6 weeks. The cavity cleared and later cultures were negative for fungus. He had further chest wall surgery and recovered well from this complication, but he died of mesothelioma 8 months later. The authors concluded that this topical antifungal approach was effective in this complex case. The article did not describe the patient's asbestos exposure.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: one 63-year-old man, a former shipyard worker, treated at Blackpool Teaching Hospital (UK) after a right extrapleural pneumonectomy and adjuvant chemoradiotherapy for stage 1b malignant epithelioid mesothelioma
• Exposure: The article does not study asbestos exposure. It states only that the patient was an ex-shipyard worker. The case concerns an Aspergillus fumigatus infection after mesothelioma surgery and chemoradiotherapy.
• Main results:
  • Cultures of samples from the patient's pleural cavity grew Aspergillus fumigatus
  • Systemic antifungal treatment (voriconazole, then caspofungin after liver enzymes rose) had a limited response in this patient
  • About 4 vials (200 mg) of amphotericin B deoxycholate were mixed in 4 gm of Spongostan gelatine powder and applied to the whole right pleural cavity
  • After the procedure, the patient took oral posaconazole 400 mg every 12 hours for 6 weeks
  • Serial cultures were then negative for fungus but remained positive for pseudomonas
  • The patient recovered well from this complication but died of mesothelioma 8 months later
• The authors' conclusion: The authors concluded that topical application of an antifungal in a vehicle allowing extensive local exposure was effective in this complex case of fungal empyema.

Topics

Medical terms in this study, explained in our Lexicon: Empyema, Extrapleural Pneumonectomy (EPP), Mesothelioma.

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