PULMONARY RESECTION FOR INVASIVE ASPERGILLUS INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

Standard antifungal medical therapy of invasive pulmonary aspergillosi s that occurs in immunocompromised patients with hematologic diseases with neutropenia or in liver transplant recipients results in less tha n a 5% survival. In view of these dismal mortality rates, we adopted a n aggressive approach with resection of the involved area of lung alon g with systemic antifungal therapy when localized invasive pulmonary a spergillosis developed in these patients, Between January 1987 and Dec ember 1993, 14 patients with hematologic diseases and 2 liver transpla nt recipients underwent resection of acute localized pulmonary masses suggestive of invasive pulmonary aspergillosis a median of 7.5 days (r ange 1 to 45 days) after the diagnosis was clinically suggested and co nfirmed by chest computed tomographic scans, Operative procedures done included two pneumonectomies, one bilobectomy with limited thoracopla sty, nine lobectomies, and five wedge resections (one patient with hem atologic disease had two procedures), All patients were treated before and after the operation with antifungal agents, Nine (64%) of 14 pati ents with hematologic disease and 2 (100%) of 2 liver transplant recip ients survived the hospitalization with no evidence of recurrent Asper gillus infection after a median 8 months of follow-up (range 3 to 82 m onths), The five hospital deaths (all patients with hematologic diseas es) occurred a median of 20 days after operation from diffuse alveolar hemorrhage in three, graft-versus-host disease in one, and multiple o rgan system failure with presumed disseminated Aspergillus infection i n one, Four of the five deaths were in patients with allogeneic bone m arrow transplants. Two of the three patients requiring resection of mu ltiple foci of infection died, as did the only patient who was preoper atively ventilator dependent, In immunocompromised patients with hemat ologic diseases or liver transplantation with invasive pulmonary asper gillosis, early pulmonary resection should be strongly considered when the characteristic clinical and radiographic pictures appear.