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Abstract

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Article in Japanese

Case Report

Allergic bronchopulmonary aspergillosis followed by Aspergillus empyema developed after anti-TNF therapy

Kei Nakashima  Shinichiro Okamoto  Shinsuke Tsumura  Nahoko Sato  Yohei Migiyama  Hirotsugu Kohrogi 

Department of Respiratory Medicine, Kumamoto University Hospital

ABSTRACT

A 55-year-old man with rheumatoid arthritis and chronic obstructive pulmonary disease developed fever, cough, and shortness of breath one month after administration of the anti-TNF infliximab, although the chest X-ray obtained before anti-TNF therapy showed only emphysematous changes. Antibacterial agents had no effect. Chest computed tomography scan revealed non-segmental ground-glass opacities and consolidations, with slight pleural effusions in the left thorax. Eosinophil counts in the peripheral blood, bronchoalveolar lavage fluid, and pleural effusion were extremely high. Both Aspergillus-specific IgE and IgG antibodies were present. These data suggested allergic bronchopulmonary aspergillosis-like features. Systemic corticosteroid therapy attenuated eosinophilia and decreased the titers of Aspergillus-specific antibodies. However, the thoracic lesions deteriorated and pulmonary empyema with fistula developed even after antifungal therapy with micafungin had been added. We performed open window thoracostomy. Culture of both resected lung and pleural effusion established Aspergillus fumigatus. We added combination antifungal therapy of voriconazole and micafungin followed by monotherapy with oral voriconazole, and performed daily thoracic cavity washing. The patient’s thorax was successfully repaired by omental flap and thoracoplasty five months after thoracostomy. Although it is considered a rare complication of anti-TNF therapy for Aspergillus to be a causative pathogen, the immunomodulatory effect of TNF inhibitors may play a crucial role in the pathogenesis of aspergillosis.

KEYWORDS

Tumor necrosis factor  Allergic bronchopulmonary aspergillosis  Rheumatoid arthritis  Open-window thoracostomy 

Received 27 Jan 2017 / Accepted 23 Aug 2017

AJRS, 6(6): 431-435, 2017

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