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A 61-year-old man presented to the ED with fever, chills, cough, purulent sputum, and progressive shortness of breath for 7 days. The patient was an active smoker with at least 80 pack-year smoking history. He had no other medical or surgical history and was not on any medication at home., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

A 60-year-old man was admitted to the hospital with productive cough and yellowish sputum, severe fatigue, and weight loss of 4 kg over the past month; furthermore, he reported a slowly progressive shortness of breath on exertion over the past 6 months. Before admission, he received ampicillin/sulbactam (750 mg) orally twice daily for 7 days without significant clinical improvement., (Copyright © 2018 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Case Presentation: An African American man in his late 30s was referred to the pulmonary clinic for evaluation of a persistent cough of several weeks' duration. Cough was productive of mucopurulent sputum mixed with blood. He also noted generalized weakness and dyspnea with minimal exertion., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Long-term antifungal therapy is usually the only treatment option for chronic pulmonary aspergillosis. However, response rates are difficult to compare because the reported clinical, mycologic, or radiologic criteria are not standardized. Objective parameters are therefore needed. To define the most relevant CT imaging variables in assessment of response to treatment, we investigated changes over time in CT imaging variables., Methods: Changes in CT imaging variables were assessed by systematic analysis of the CT scan findings of 36 patients at diagnosis and 6 months after initiation of treatment. The relevant radiologic variables were determined by selecting those showing significant changes over time. Two experienced thoracic radiologists, blinded for clinical and serologic response, independently performed CT scan analyses. Interreader agreement and concordance between radiologic and clinical response were evaluated., Results: Of the 36 patients, seven experienced clinical deterioration while undergoing therapy. Significantly evolving radiologic variables included cavity and pleural wall thickening (P < .05), which were associated with clinical improvement. There was a strong association between fungus ball disappearance and cavity/pleural wall thickening reduction and clinical improvement (P = .04). There was poor agreement between size changes of cavities or nodules, and clinical evolution (Cohen's κ, -0.13 to -0.24)., Conclusions: Variations in cavity and pleural wall thickness may be the most relevant CT imaging variables for assessing response to treatment. Loss of fungus ball is strongly associated with clinical and radiologic improvement, but cavity size changes are unrelated to chronic pulmonary aspergillosis evolution. All these CT imaging variables may be applied in future clinical trials to assess treatment outcome., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

A 60-year-old asymptomatic woman was referred to our hospital because of an abnormal chest roentgenogram during a routine medical checkup. The patient had no history of memorable infectious diseases, except a liver abscess caused by Serratia marcescens at age 46 years. Her son was diagnosed with chronic granulomatous disease at the age of 1 year. She had never smoked cigarettes and drank only occasionally.

Both inherited and acquired immunodeficiency and chronic pulmonary disease predispose to the development of a variety of pulmonary syndromes in response to Aspergillus, a fungus that is ubiquitous in the environment. These syndromes include invasive aspergillosis, which is now recognized to occur in patients with critical illness without neutropenia and in those with mild degrees of immunosuppression, including from corticosteroid use in the setting of COPD. Chronic pulmonary aspergillosis includes simple aspergilloma, which is occasionally complicated by life-threatening hemoptysis, and progressive destructive cavitary disease requiring antifungal therapy. Allergic bronchopulmonary aspergillosis occurs almost exclusively in patients with asthma or cystic fibrosis. Recent advances in each of these syndromes include a greater understanding of the underlying pathophysiology and hosts at risk; improved diagnostic algorithms; and the availability of more effective and well-tolerated therapies. Improvement in outcomes for Aspergillus pulmonary syndromes requires that physicians recognize the varied and sometimes subtle presentations, be aware of populations at risk of illness, and institute potentially life-saving therapies early in the disease course.

Background: Multiple causes for tree-in-bud (TIB) opacities have been reported. However, to our knowledge the relative frequencies of the causes have not been evaluated. The purpose of this study was to determine the relative frequency of causes of TIB opacities and identify patterns of disease associated with TIB opacities., Methods: Cases with TIB opacities in the radiology report in 2010 were identified by searching the Radiology Information System. Medical records and CT scan examinations were reviewed for the causes of TIB opacities. Patterns of disease associated with TIB opacities were evaluated., Results: Causes for TIB opacities were established in 166 of 406 (40.9%) cases. Respiratory infections (119 of 166, 72%) with mycobacteria (65 of 166, 39%), bacteria (44 of 166, 27%), viruses (four of 166, 3%), or multiple organisms (six of 166, 4%) were most common. Aspiration was the cause in 42 of 166 (25%). Alternating areas of normal lung with regions of small airways disease (TIB opacities, bronchiectasis) (random small airways pattern) was specific (0.92) for Mycobacterium avium complex infection. Nearly uniform distribution of bronchiectasis (widespread bronchiectasis pattern) was specific for "diseases predisposing to airway infection" (specificity 0.92), such as cystic fibrosis, primary ciliary dyskinesia, allergic bronchopulmonary aspergillosis, and immunodeficiency states. Consolidation and TIB opacities (bronchopneumonia pattern) were usually due to bacterial infection or aspiration. Dependent distribution (specificity 0.79) and esophageal abnormality (specificity 0.86) with TIB opacities were associated with aspiration. Chronicity of findings was associated with mycobacterial infection (P &lt; .0001, sensitivity 0.96). Acuteness of findings was associated with bacterial infection (P &lt; .001, specificity 0.87)., Conclusions: TIB opacities are most often a manifestation of infections or aspiration. Patterns of disease can provide clues to the most likely diagnosis.

Background: A serum galactomannan (GM) assay has been approved for diagnosing invasive aspergillosis (IA). However, the role of the BAL-GM assay has not been well established. Therefore, we conducted a metaanalysis to determine the overall accuracy of BAL-GM in the diagnosis of IA., Methods: After a systematic review of English-language studies, the sensitivity (SEN), specificity (SPE), and positive and negative likelihood ratios (PLR and NLR, respectively) of BAL-GM for the diagnosis of IA were pooled using a bivariate metaanalysis. Hierarchic summary receiver operating characteristic curves were used to summarize overall test performance. Potential between-study heterogeneity was explored by subgroup analyses. We calculated posttest probability to evaluate clinical usefulness., Results: Twelve reports, including 13 studies, met our inclusion criteria. The summary estimates of the BAL-GM assay for proven or probable IA were as follows: SEN, 0.90 (95% CI, 0.79-0.96); SPE, 0.94 (95% CI, 0.90-0.96); PLR, 14.87 (95% CI, 8.89-24.90); and NLR, 0.10 (95% CI, 0.04-0.24). The four summary estimates of the BAL-GM assay for proven IA were 0.94 (95% CI, 0.86-0.98), 0.79 (95% CI, 0.68-0.86), 4.41 (95% CI, 2.87-6.77), and 0.07 (95% CI, 0.03-0.09), respectively. Significant heterogeneity was present., Conclusions: BAL-GM determination is a sensitive and specific test for the diagnosis of proven and probable IA. The measurement of BAL-GM is thus likely to be a useful tool for diagnosing IA. Further studies focused on the impact of treatment agents are needed.

Background: Invasive pulmonary aspergillosis (IPA) is difficult to diagnose. The detection of galactomannan (GM) in serum samples is useful for diagnosing IPA. A positive test for GM antigen in BAL has also been proposed as a criterion of IPA, although it has not been fully validated. The aim of our study was to evaluate the contribution of GM antigen detection in BAL to the diagnosis of IPA in hematologic patients., Methods: One hundred one consecutive patients treated for hematologic malignancy were explored by bronchoscopy and BAL for new pulmonary infiltrates. Both BAL fluid and serum samples were evaluated for GM using an enzyme-linked immunosorbent assay test, with an optical density index >or= 0.5 considered positive. Respiratory samples were also examined for the presence of fungi., Results: IPA was diagnosed in 33 patients according to European Organization for Research and Treatment of Cancer and Mycoses Study Group consensus group criteria (six proven, 23 probable, four possible). Nineteen of these 33 patients had a positive BAL GM test, whereas three patients without IPA had false-positive results. GM detection in BAL had a sensitivity of 57.6% (95% CI, 40.8%-72.8%) and a specificity of 95.6% (95% CI, 87.8%-98.5%). Among the 19 patients with IPA whose BAL was positive for GM, 15 also had a positive serum GM test. In 11 of these 19 patients, Aspergillus was identified in the respiratory samples., Conclusion: Detection of GM in BAL is complementary of serum GM testing and mycologic evaluation of the respiratory samples for the diagnosis of IPA. Positive GM BAL was the sole microbiologic criterion in two of 33 patients studied.