Case of the Month

Invasive pulmonary aspergillosis after liver transplantation.

Figure 1.(A) AP Supine radiograph. (B-D) CT Pulmonary Window, axial, sagittal, and coronal reconstructions, respectively. Multiple thick-walled cavities of varying sizes, and areas containing a Tree-in-Bud pattern are present in both Upper and Lower Lobes. An intracavitary aspergilloma is  seen in the anterior segment of the LUL (Circles). A large mucoid impaction (Arrow) with distal air-trapping (Asterisk) is present in the Lingula. Mucoid impactions are present in both Lower Lobes.

Figure 2. Due to the patient’s neurologic symptoms an MRI scan was performed. The heterogeneous lesion in the right Frontal lobe (Circle) was biopsied.

Figure 3. Brain biopsy specimen. (A) H&E stain, 100X. Septated hyphae at 45°angles (Circle)  on necrotic background, compatible with Aspergillosis are present (B) Gomori Stain 100X. Septated, Gomori positive hyphae are seen. (C) PAS Stain 100X. Septated PAS positive hyphae are present.

Mainly seen in patients with prolonged neutropenia, transplant recipients, and patients with AIDS or chronic granulomatous disease. Cough, dyspnea and fever are common. Infection can extend to mediastinal and chest-wall structures. Hematogenous dissemination can involve virtually any organ, including the brain.

Invasive aspergillosis has been reported in 1 to 8% of liver transplant recipients.Infection typically occurs in the early post-transplant period.

CT findings commonly include pulmonary nodules with a surrounding ground-glass halo, and pleural-based, wedge-shaped areas of consolidation. Intracavitary aspergillomas with an air crescent sign when seen in angioinvasive aspergillosis are usually seen during convalescence. In the present case, cavitated lesions and mucoid impactions were also seen.

Voriconazole is recommended as first-line therapy for IPA, as it is associated with a lower mortality rate compared with amphotericin B. Isavuconazole is equally effective as voricanazole but less toxic. IPA should be treated with at least 12 weeks of antifungal therapy, although longer treatment courses may be required depending on clinical response and ongoing immunosuppression.

1. Segal BH. Aspergillosis. N Engl J Med 2009;360:1870-84.
2. Franquet T, Müller NL, Giménez A, et al. Spectrum of pulmonary aspergillosis: Histologic, clinical, and radiologic findings. Radiographics. 2001; 21:825–837.
3. Singh N and Paterson DL. Aspergillus infections in transplant recipients Clinical Microbiology Reviews. 2005; 18:44–69.
4. Tempkin AD, Sobonya RE, Seeger JF, and Oh ES. Best cases from the AFIP. Cerebral aspergillosis: Radiologic and pathologic findings. RadioGraphics 2006; 26:1239–1242.