MANAGEMENT OF PULMONARY ASPERGILLOSIS IN AIDS - AN EMERGING CLINICAL PROBLEM

Aims-To review the clinical, radiographic, and therapeutic features of 11 cases of respiratory Aspergillus infection in patients with AIDS. Methods-All induced sputum and bronchoalveolar lavage samples obtained from HIV seropositive patients between 1985 and March 1993 were for A spergillus species. Additionally, where appropriate, bronchial or rena l biopsy specimens, or both, were taken before treatment had started. Results-In 11 patients Aspergillus fumigatus was identified in alveola r samples obtained by sputum induction. This was confirmed by bronchoa lveolar lavage in eight. Three patients had Aspergillus plaques in the trachea and bronchus, while a fourth patient had an aspergilloma. Ris k factors for Aspergillus infection were present in all patients, incl uding corticosteroid treatment in three cases and neutropenia in four, three of whom had received chemotherapy for Kaposi's sarcoma. Four pa tients had concomitant cytomegalovirus infection. Ten patients had a C D4 count of less than 50 cells/mm(3) while one patient had a dissemina ted T cell lymphoma with a CD4 count of 242 cells/mm(3). Of the three patients with samples obtained by sputum induction who did not undergo bronchoscopy, two had a normal chest x ray picture and the third had a right lobar pneumonia complicating an aggressive lymphoma. All three were treated with itraconazole 200 mg twice a day without further inv estigation. Survival from the time of diagnosis of Aspergillus infecti on was short: seven patients died within six weeks, although only one death was directly attributed to pulmonary aspergillosis. At six month ly follow up, one patient, who initially had a positive Aspergillus cu lture from bronchial washings and a normal chest radiograph, developed a renal aspergilloma despite the disappearance of Aspergillus sp from the sputum. Conclusion-Pulmonary aspergillosis is an important clinic al problem in patients with AIDS with a CD4 count of less than 50 cell s/mm.(3) Furthermore, patients with Aspergillus sp in sputum induction or bronchial washings may develop disseminated disease despite adequa te treatment of the primary infection.