INVASIVE ASPERGILLOSIS IN PATIENTS WITH ACQUIRED-IMMUNODEFICIENCY-SYNDROME - REPORT OF 33 CASES

PURPOSE: Acquired immunodeficiency syndrome (AIDS)-associated invasive aspergillosis (IA) is a rare condition, which is mainly reported as i solated cases either antemortem or at autopsy. The role of AIDs itself is controversial, because many of the reported patients exhibited the classic risk factors such as neutropenia and steroid therapy. The aim s of this study were to report 33 patients with IA during AIDS and the ir outcome, focusing on the risk factors and the value of diagnostic p rocedures. PATIENTS AND METHODS: Thirty-three patients from 17 differe nt medical centers in France were retrospectively included in the stud y. For pulmonary IA, we defined two types Of patients: those with ''co nfirmed IA,'' describing all the patients with histologically proven d isease, and those with ''probable IA,'' who had the development of a n ew pulmonary infiltrate on chest radiograph and a positive bronchoalve olar lavage (BAL) fluid culture for Aspergillus species without identi fication of other pathogens. For extrapulmonary IA, the diagnostic cri teria included both positive histology and culture. RESULTS: Of the 33 cases included in this series, 91% were recorded during the last 3 ye ars (1989 to 1991), suggesting that aspergillosis is an emerging compl ication in AIDS. Approximately 50% of the patients did not exhibit any classic risk factor, i.e, neutropenia and steroid treatment; almost a ll patients had a CD4 cell count less than 50/mm3. The mycologic cultu re from BAL was the method of choice for the diagnosis of invasive pul monary disease because it was known to correlate well with histologic findings obtained either antemortem or postmortem. Of 28 patients with a positive BAL culture for Aspergillus, 15 underwent a biopsy or auto psy and 14 were positive at histology. Serum antigen detection was pos itive in only 4 of 16 tested patients. Clinical and radiologic signs d id not differ from those observed in neutropenic patients without huma n immunodeficiency virus, except for the higher incidence of neurologi c complications in AIDS. Interestingly, we observed three cases of inv asive necrotizing tracheobronchial aspergillosis with acute dyspnea an d wheezing. The use of amphotericin B (0.5 mg/kg/d) and/or itraconazol e (200 to 600 mg/d) was most often unsuccessful. Only four patients ex perienced clinical and radiologic improvement. The mean interval betwe en the diagnosis of IA and death was 8 weeks (range: 3 days to 13 mont hs). CONCLUSIONS: This study suggests that aspergillosis is an importa nt life-threatening condition in the advanced stage of AIDS. It requir es an early diagnosis with BAL fluid culture and careful therapeutic e valuation.