Successful treatment of chronic necrotizing pulmonary aspergillosis with long-term oral administration of itraconazole

History and admission findings: A 66-year-old man with bullous pulmonary em physema, was being treated with oral prednisone, had over the previous two month experienced dyspnoea, productive cough and an 8 kg weight loss. Physi cal examination revealed inspiratory rales over the right middle robe, with faint vesicular breathing in the other lobes. Investigations: Inflammation parameters were markedly elevated (WBC 24 800/ mu l, C-reactive protein 28.6 mg/dl), while the chest radiograph showed liq uid infiltrates in the right upper and middle lobes. Despite administration of antibiotics the infiltrates persisted. Aspergillus fumigatus was demons trated in bronchial secretion. Treatment and course: Antifungal treatment with itraconazole (400 mg/d) was started and resulted in marked subjective improvement, normalization of th e inflammation parameters and slow regression of the pulmonary infiltrates. Thoracic computed tomography one year later merely revealed residual posti nflammatory changes. Conclusion: An insidious course and treatment-resistant lung infiltrates in patients with steroid treatment should suggest chronic necrotizing pulmona ry aspergillosis and this pathogen should be looked for in bronchial secret ions. Antifungal treatment with itraconazole is essential and efficacious.