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Objective: To build and merge a diagnostic model called multi-input DenseNet fused with clinical features (MI-DenseCFNet) for discriminating between Staphylococcus aureus pneumonia (SAP) and Aspergillus pneumonia (ASP) and to evaluate the significant correlation of each clinical feature in determining these two types of pneumonia using a random forest dichotomous diagnosis model. This will enhance diagnostic accuracy and efficiency in distinguishing between SAP and ASP., Methods: In this study, 60 patients with clinically confirmed SAP and ASP, who were admitted to four large tertiary hospitals in Kunming, China, were included. Thoracic high-resolution CT lung windows of all patients were extracted from the picture archiving and communication system, and the corresponding clinical data of each patient were collected., Results: The MI-DenseCFNet diagnosis model demonstrates an internal validation set with an area under the curve (AUC) of 0.92. Its external validation set demonstrates an AUC of 0.83. The model requires only 10.24s to generate a categorical diagnosis and produce results from 20 cases of data. Compared with high-, mid-, and low-ranking radiologists, the model achieves accuracies of 78% vs. 75% vs. 60% vs. 40%. Eleven significant clinical features were screened by the random forest dichotomous diagnosis model., Conclusion: The MI-DenseCFNet multimodal diagnosis model can effectively diagnose SAP and ASP, and its diagnostic performance significantly exceeds that of junior radiologists. The 11 important clinical features were screened in the constructed random forest dichotomous diagnostic model, providing a reference for clinicians., Clinical Relevance Statement: MI-DenseCFNet could provide diagnostic assistance for primary hospitals that do not have advanced radiologists, enabling patients with suspected infections like Staphylococcus aureus pneumonia or Aspergillus pneumonia to receive a quicker diagnosis and cut down on the abuse of antibiotics., Key Points: • MI-DenseCFNet combines deep learning neural networks with crucial clinical features to discern between Staphylococcus aureus pneumonia and Aspergillus pneumonia. • The comprehensive group had an area under the curve of 0.92, surpassing the proficiency of junior radiologists. • This model can enhance a primary radiologist's diagnostic capacity., (© 2024. The Author(s).)

Pulmonary scedosporiosis is a rare pulmonary infection that often presents with nonspecific symptoms and radiological findings. In this report, we present a case of localized pulmonary scedosporiosis in an immunocompetent patient and analyze a total of 25 immunocompetent patients with pulmonary scedosporiosis. Through this case and the literature, we highlight the importance of considering pulmonary scedosporiosis in patients with nonspecific clinical symptoms and radiological findings resembling aspergilloma. This case and the literature further emphasize the significance of surgical intervention. Regardless of the use of antifungal drugs, surgery should be conducted as soon as possible., (© 2024 The Authors. The Clinical Respiratory Journal published by John Wiley & Sons Ltd.)

Imaging plays an important role in the various forms of Aspergillus -related pulmonary disease. Depending on the immune status of the patient, three forms are described with distinct imaging characteristics: invasive aspergillosis affecting severely immunocompromised patients, chronic pulmonary aspergillosis affecting less severely immunocompromised patients but suffering from a pre-existing structural lung disease, and allergic bronchopulmonary aspergillosis related to respiratory exposure to Aspergillus species in patients with asthma and cystic fibrosis. Computed tomography (CT) has been demonstrated more sensitive and specific than chest radiographs and its use has largely contributed to the diagnosis, follow-up, and evaluation of treatment in each condition. In the last few decades, CT has also been described in the specific context of cystic fibrosis. In this particular clinical setting, magnetic resonance imaging and the recent developments in artificial intelligence have shown promising results., Competing Interests: None declared., (Thieme. All rights reserved.)

Pulmonary aspergillosis is a group of mycotic diseases affecting the lungs. The form of the disease mainly depends on the immune status of the patient and underlying conditions. Invasive pulmonary aspergillosis usually affects immunocompromised patients - angio-invasive and airway-invasive forms are possible. Chronic aspergillosis usually appears in mildly immunosuppressed or immunocompetent patients with underlying structural lung changes and may have diverse forms: simple aspergilloma, chronic cavitary pulmonary aspergillosis, chronic fibrosing pulmonary aspergillosis, subacute invasive pulmonary aspergillosis, aspergillus nodules and endobronchial aspergilloma. Allergic bronchopulmonary aspergillosis is a hyper-reactivity reaction to Aspergillus species, and usually develops in asthma and cystic fibrosis patients. The aim of this article is to comprehensively overview different forms of aspergillosis, their symptoms and underlying conditions and to present imaging findings., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective Chronic pulmonary aspergillosis (CPA) is an important complication of nontuberculous mycobacterial pulmonary disease (NTM-PD). However, its diagnosis is challenging, as both CPA and NTM-PD present as chronic cavitary disease. The present study evaluated the impact of CPA on the survival of patients with NTM-PD and revealed the key computed tomography findings for a prompt diagnosis. Methods We retrospectively reviewed patients newly diagnosed with NTM-PD in Tenri Hospital (Tenri City, Nara Prefecture, Japan) between January 2009 and March 2018; the patients were followed up until May 2021. Clinical and radiological characteristics were assessed, and patients with CPA were identified. Results A total of 611 patients were diagnosed with NTM-PD. Among them, 38 (6.2%), 102 (17%), and 471 (77%) patients were diagnosed with NTM-PD with CPA, cavitary NTM-PD without CPA, and non-cavitary NTM-PD without CPA, respectively. The 5-year survival rate of the NTM-PD with CPA group (42.8%; 95% confidence interval: 28.7-64.0%) was lower than that of the cavitary NTM-PD without CPA group (74.4%; 95% confidence interval: 65.4-84.6%). A multivariate analysis revealed that fungal balls and cavities with adjacent extrapleural fat were significant predictive factors for NTM-PD with CPA. Conclusion NTM-PD with CPA patients exhibited a worse prognosis than cavitary NTM-PD without CPA patients. Therefore, an unerring diagnosis of CPA is essential for managing patients with NTM-PD. Computed tomography findings, such as fungal balls and cavities with adjacent extrapleural fat, may be valuable diagnostic clues when CPA is suspected in patients with NTM-PD.

We present a case of a woman in her 70s, with a history of Mycobacterium avium complex (MAC) pulmonary disease, pectus excavatum, s-shaped thoracolumbar scoliosis, bronchiectasis of the right middle lobe, lingula of left upper lobe, and malnutrition with low body mass index of 14 kg/m 2 , who presented to the hospital due to worsening shortness of breath and small volume haemoptysis over 2 weeks. The patient was diagnosed with pulmonary MAC infection for the first time in 1999 without known history of pulmonary disease. Later on, it was complicated by massive haemoptysis requiring bronchial artery embolisation; however, she was unable to complete an oral antibiotic regimen due to gastrointestinal adverse reactions. Chest CT identified a newly found mass in the left upper lobe bulla, consistent with a radiological finding of aspergilloma. We present a rare symptoms constellation, described as 'Lady Windermere syndrome' and chronic untreated MAC infection progressing from reticulonodular changes to fibrocavitary lung disease and suspected aspergilloma formation., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pulmonary aspergillosis is a pulmonary infectious disease that is clinically difficult to diagnose and treat. When the lower respiratory tract is invaded by Aspergillus, the clinical manifestations and imaging features vary among patients with different immune states. The use of antifungal drugs and glucocorticoids are important, but some patients do not respond satisfactorily to treatment., Case Presentation: A 59-year-old female had a long history of asthma and poor symptom control, with long-term use of long-acting inhaled glucocorticoids combined with a long-acting β2 receptor agonists (ICS + LABA) (salmeterol fluticasone inhalation powder). The ground glass shadow, tree-in-bud sign, and bronchiectasis in the middle lobe of the right lung and the lower lobe of both lungs were first detected by chest CT over 5 years ago. Atelectasis in the middle lobe of the right lung was detected over 3 years ago. Over 2 years ago, the patient was hospitalized and a repeat chest CT showed persistent atelectasis in the middle lobe of the right lung, and more lesions in bilateral lower lungs than before. Aspergillus fumigatus was detected in alveolar lavage fluid and sputum pathogenic culture, which confirmed the diagnosis of pulmonary aspergillosis. After treatment with voriconazole and amphotericin B, the middle lobe of the right lung partially reopened, but the lesions in bilateral lower lungs persisted. After 21 weeks of treatment, the antifungal drugs were stopped because the patient refused to use oral/intravenous glucocorticoids, and omalizumab was finally chosen for treatment. After 1 month of treatment, the patient's clinical symptoms began to ease. After 1 year of treatment, imaging reexamination of lung showed that the lesions were completely cleared, accompanied by significant improvement in nutritional status and airway function., Conclusions: We reported the case of a patient with pulmonary Aspergillus infection who was treated with omalizumab and showed significant improvement in clinical symptoms and imaging abnormalities, which provides a new option for patients with pulmonary Aspergillus infection who show unsatisfactory response with first-line drugs., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Chronic cavitary pulmonary aspergillosis (CCPA) is the most common form of chronic pulmonary aspergillosis., Objective: We hypothesise that by observing serial clinical and CT findings of CCPA patients with antifungal therapy, factors helping predict responses to antifungal therapy could be withdrawn., Methods: A total of 31 patients with CCPA who received antifungal therapy for greater than six months and who had serial CT studies were included. Clinical finding analyses were performed at initial and last follow-up CT acquisition dates. Clinical characteristics and CT features were compared between clinically improving or stable and deteriorating groups., Results: With antifungal therapy, neutrophil-to-lymphocyte ratio (2.66 vs. 5.12, p = .038) and serum albumin (4.40 vs. 3.85 g/dl, p = .013) and CRP (1.10 vs. 42.80 mg/L, p = .007) were different between two groups. With antifungal therapy, meaningful CT change, regardless of clinical response grouping, was decrease in cavity wall thickness (from 13.70 mm to 8.28 mm, p < .001). But baseline (p = .668) and follow-up (p = .278) cavity wall thickness was not different between two groups. In univariate analysis, initial maximum diameter of cavity (p = .028; HR [0.983], 95% CI [0.967-0.998]) and concurrent NTM infection (p = .030; HR [0.20], 95% CI [0.05-0.86]) were related factors for poor clinical response., Conclusions: With antifungal therapy, cavities demonstrate wall thinning. Of all clinical and radiological findings and their changes, initial large cavity size and concurrent presence of NTM infection are related factors to poor response to antifungal therapy., (© 2022 Wiley-VCH GmbH.)

Chronic pulmonary aspergillosis (CPA) is a life-threatening respiratory fungal infection that is almost exclusively seen in patients with preexisting structural lung disease with no or mild immunosuppression. The clinical presentation and imaging findings are varied and often pose a diagnostic challenge; and the disease is often present for a long time before being correctly diagnosed. High-resolution chest computed tomography is the imaging modality of choice because it helps identify various forms of CPA, which can range from a simple aspergilloma and chronic cavitary form, to the subacute invasive and end-stage fibrotic form. The knowledge of the imaging features of this disease cannot be overemphasized because it can assist the clinician in reaching at an early diagnosis and timely initiation of appropriate antifungal therapy, thereby improving patient management and treatment outcome. Moreover, imaging also plays a pivotal role during follow-up in patients of CPA to assess the treatment response. In the current review, we present an illustrative review of radiologic patterns seen in various forms of CPA.

Tracheal sleeve pneumonectomy consists of en bloc resection of the lung, main bronchus plus a section of the carina and its subsequent anastomosis with the remaining main-stem bronchus. We present the unique case of a 56-year-old patient, who underwent tracheal sleeve pneumonectomy for a complex pulmonary aspergilloma invading almost the entire right lung up to the carina., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Purpose: Common CT abnormalities of pulmonary aspergillosis represent a cavity with air-meniscus sign, nodule, mass, and consolidation having an angio-invasive pattern. This study aims to conduct a systematic review and an individual patient-level image analysis of CT findings of COVID-19-associated pulmonary aspergillosis (CAPA)., Methods: A systematic literature search was conducted to identify studies reporting CT findings of CAPA as of January 7, 2021. We summarized study-level clinical and CT findings of CAPA and collected individual patient CT images by inviting corresponding authors. The CT findings were categorized into four groups: group 1, typical appearance of COVID-19; group 2, indeterminate appearance of COVID-19; group 3, atypical for COVID-19 without cavities; and group 4, atypical for COVID-19 with cavities. In group 2, cases had only minor discrepant findings including solid nodules, isolated airspace consolidation with negligible ground-glass opacities, centrilobular micronodules, bronchial abnormalities, and cavities., Results: The literature search identified 89 patients from 25 studies, and we collected CT images from 35 CAPA patients (mean age 62.4 ± 14.6 years; 21 men): group 1, thirteen patients (37.1%); group 2, eight patients (22.9%); group 3, six patients (17.1%); and group 4, eight patients (22.9%). Eight of the 14 patients (57.1%) with an atypical appearance had bronchial abnormalities, whereas only one (7.1%) had an angio-invasive fungal pattern. In the study-level analysis, cavities were reported in 12 of 54 patients (22.2%)., Conclusion: CAPA can frequently manifest as COVID-19 pneumonia without common CT abnormalities of pulmonary aspergillosis. If abnormalities exist on CT images, CAPA may frequently accompany bronchial abnormalities., Competing Interests: Declaration of competing interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Soon Ho Yoon works in the MEDICALIP as a chief medical officer. Philipp Koehler is supported by the German Federal Ministry of Research and Education and the State of North Rhine-Westphalia, Germany and has received non-financial scientific grants from Miltenyi Biotec GmbH, Bergisch Gladbach, Germany, and the Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany, and received lecture honoraria from and/or is advisor to Akademie für Infektionsmedizin e.V., Ambu GmbH, Astellas Pharma, European Confederation of Medical Mycology, Gilead Sciences, GPR Academy Ruesselsheim, MSD Sharp & Dohme GmbH, Noxxon N.V., and University Hospital, LMU Munich outside the submitted work. Other authors have no conflicts of interest to declare for this article., (Copyright © 2022. Published by Elsevier Inc.)

Amongst various manifestations of pulmonary aspergillosis, chronic pulmonary aspergillosis (CPA) is the most common. We conducted this study to identify different morphological forms of CPA, on computed tomography angiography (CTA), and to correlate these with clinical presentation, as well as, associated imaging features. The study design was cross-sectional, with a final sample size of 65 patients, recruited over a period of 2years from January 2017 to October 2018. Patients with past history of tuberculosis (TB), presenting with haemoptysis and found to have aspergilloma on computed tomography and lab tests were included in the study. All patients underwent CTA for evaluation of haemoptysis. Three morphological types of intracavitary aspergilloma on imaging were identified: type 1-nodular soft tissue along the cavity-wall, type-2 soft tissue density with multiple air lucencies and type-3 homogenous soft tissue opacity with air-crescent sign. Aspergilloma types were correlated with grade and duration of haemoptysis, associated imaging findings and vascularity score on CTA. Mean age of the patients was 40.97 +/- 13.69 years. As the type of aspergilloma changed from 1 to 3, there was a decrease in cavity wall thickness, peri-cavitary inflammation and vascularity. It is the type 1 and 2 aspergillomas, which caused more inflammation in the lungs, and hence recruited more abnormal vasculature. No significant correlation was found between haemoptysis severity and type of aspergilloma; type 3 aspergilloma however had longer duration of haemoptysis. In conclusion, the initial stages of formation of aspergilloma (type 1 and 2) cause more parenchymal inflammation and symptoms. The classical Monod sign is observed in the late stage of aspergilloma, since the peri-cavitary inflammation is reduced by then and thus the symptoms., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Endobronchial aspergilloma is a rare disease. A 64-year-old man with severe diabetes mellitus developed a cough and fever and was referred to our hospital. He was diagnosed with obstructive pneumonia associated with endobronchial aspergilloma, underwent interventional bronchoscopy, and was treated with antifungals. While the optimal treatment has not been established, interventional bronchoscopy along with systemic antifungals may improve the outcome in such cases.

Objectives: Chronic pulmonary aspergillosis (CPA) can complicate recovery from pulmonary TB. CPA may also be misdiagnosed as bacteriologically negative TB. This study aimed to determine the incidence of CPA in patients treated for TB in Indonesia, a country with a high incidence of TB., Methods: In this prospective, longitudinal cohort study in patients treated for pulmonary TB, clinical, radiological and laboratory findings were analysed. Sputum was collected for fungal culture and TB PCR. Patients were assessed at baseline (0-8 weeks) and at the end (5-6 months) of TB therapy. CPA diagnosis was based on symptoms (≥3 months), characteristic radiological features and positive Aspergillus serology, and categorised as proven, probable and possible., Results: Of the 216 patients recruited, 128 (59%) were followed up until end of TB therapy. At baseline, 91 (42%) had microbiological evidence for TB. Aspergillus -specific IgG was positive in 64 (30%) patients and went from negative to positive in 16 (13%) patients during TB therapy. The incidence rates of proven and probable CPA at baseline were 6% (n=12) and 2% (n=5) and end of TB therapy 8% (n=10) and 5% (n=7), respectively. Six patients (two with confirmed TB) developed an aspergilloma. Diabetes mellitus was a significant risk factor for CPA (p=0.040). Persistent cough (n=5, 50%; p=0.005) and fatigue (n=6, 60%; p=0.001) were the most common symptoms in CPA., Conclusion: CPA should be considered a relatively frequent differential diagnosis in patients with possible or proven TB in Indonesia. Lack of awareness and limited access to Aspergillus -specific IgG tests and CT imaging are obstacles in establishing a CPA diagnosis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Non-tuberculous mycobacteria (NTM) are one of the predominant microbes observed in immunocompromised patients with structural lung disease. Especially in immunocompromised patients, the treating physician needs to be aware of concurrent lung infections with opportunistic pathogens. In this case report we present a man in his 60s with severe chronic obstructive pulmonary disease (COPD) and bullous emphysema, who was diagnosed with Mycobacterium europaeum but with persistent clinical deterioration despite relevant treatment for NTM. A subsequent bronchoalveolar lavage (BAL) revealed elevated Aspergillus galactomannan antigen which, when seen in relation to imaging-findings of cavitating opacities with aggravating surrounding consolidation, raised suspicion of concurrent subacute invasive aspergillosis. Antifungal treatment was initiated but due to intolerable side effects was discontinued after only a few weeks. This case highlights the importance of concurrent testing for pulmonary aspergillosis in NTM patients and vice versa before treatment initiation and if the disease and symptoms are progressing despite relevant treatment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Pulmonary aspergilloma affects immunocompromised patients but is also a recurrent condition in patients previously treated for pulmonary tuberculosis., Methods and Results: We report the case of a 45-year-old patient with a history of cured pulmonary tuberculosis 15 years earlier in whom we visualized pulmonary aspergilloma by transthoracic lung sonography. Sonography of pulmonary aspergilloma demonstrated an oval cavity with hypoechoic contents and an irregular border, measuring a diameter of 4.7 cm; inside the lesion, a roundish structure with an anechoic rim was discernable., Conclusions: The sonographic findings corresponded to chest X-ray and computed tomography imaging in this patient and to previously reported sonographic characteristics of mycotic abscesses in other organs. Lung ultrasound may be a tool to identify pulmonary aspergilloma, especially as a point-of-care imaging tool and where other imaging modalities are inaccessible., (© 2021. The Author(s).)

Objective: Complete resection with a clear margin is the only curative treatment for pulmonary aspergilloma. This requires a high-level technique, especially for complex aspergilloma (CA), because of patient conditions and wide dense adhesions. Fungus ball removal is used palliatively to control hemoptysis, rather than as a radical procedure, and may be performed using video-cavernoscopy as a simple and repeatable method. In this study, we examined this approach as an alternative treatment for CA., Methods: Eight cases of fungus ball removal with video-cavernoscopy (video-cavernoscopic removal) treated at our center were retrospectively reviewed. The patient characteristics and surgical outcomes were compared with those of patients treated with one-stage radical surgery., Results: There were 8 subjects (7 males, 1 female; median age 65 years) in the video-cavernoscopic removal group and 25 subjects (19 males, 6 females; median age 56 years) in the one-stage radical surgery group. The video-cavernoscopic removal group had a higher rate of emphysematous lung (p = 0.001), a lower body mass index (p = 0.039), and a lower percent vital capacity (p = 0.027). All cases in this group had preoperative hemoptysis that ceased after the procedure. Video-cavernoscopic removal was less invasive based on a shorter operative time (p = 0.000), less blood loss (p = 0.002), and a lower Common Terminology Criteria for Adverse Events grade (p = 0.023). However, four cases in this group (50%) relapsed with a median disease-free survival period of 471.5 days., Conclusions: Fungus ball removal with video-cavernoscopy is a simple technique for the prevention and control of massive hemoptysis that may be an alternative treatment for CA., (© 2021. The Japanese Association for Thoracic Surgery.)

Objective: Studies have confirmed that real-time PCR detection of Aspergillus DNA in bronchoalveolar lavage fluid (BALF) is more valuable than blood samples in the diagnosis of invasive pulmonary aspergillosis (IPA). The latest guidelines recommend the use of serum samples for Aspergillus antibody testing for chronic pulmonary aspergillosis (CPA). However, research on CPA diagnosed by real-time PCR testing of BALF has been limited. In this study, we assessed the clinical value of BALF GM and PCR detection in diagnosing CPA., Methods: The diagnostic criteria of this study were based on the 2015 ESCMID/ERS guidelines for CPA. Seventy-nine patients with CPA and 74 non-CPA patients were enrolled. Aspergillus DNA in BALF was detected in the patients with CPA., Results: The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) of BALF PCR in the CPA group were 87.18%, 89.80%, 87.18%, 89.80%, and 0.89 (95% CI 0.82-0.95), respectively ( P <0.005). The sensitivity, specificity, PPV, and NPV of BALF Aspergillus galactomannan (GM) detection in the CPA group were 66.67%, 89.80%, 83.87%, and 77.19%, respectively, and the AUC was 0.94 (95% CI 0.89-0.99) ( P <0.005). When combining BALF GM and BALF PCR detection, the sensitivity, specificity, PPV, and NPV were 92.31%, 89.80%, 87.80%, and 93.62%, respectively., Conclusion: The BALF PCR detection method has good diagnostic value for CPA and combining this method with BALF GM detection can improve diagnostic sensitivity and specificity., (© 2021 by the Association of Clinical Scientists, Inc.)

Chronic cavitary pulmonary aspergillosis (CCPA) is a slow destructive type of chronic pulmonary aspergillosis, characterised by multiple pulmonary cavities that develop and expand over several months or years. Pleural involvement in the form of pneumothorax has been rarely reported in CCPA. We report such an unusual case of an immunocompromised male, with a history of chronic cough and fever, presenting with acute onset of shortness of breath. Chest imaging showed bilateral multiple cavitating nodules, ground glass opacities and dense right middle lobe consolidations and right-sided pneumothorax. Bronchoalveolar lavage (BAL) showed septate hyaline hyphae on KOH (potassium hydroxide) staining and fungal culture grew Aspergillus fumigatus BAL and serum galactomanan were positive and serum IgG for A. fumigatus was 58 MgA/L (0-40MgA/L) confirming the cause of spontaneous secondary pneumothorax in our patient as CCPA., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

We experienced a case of the successful treatment of intractable pulmonary aspergillosis with inhaled liposomal amphotericin B (L-AMB) and oral voriconazole (VRCZ). A 52-year-old man was admitted to our hospital with a fever. Chest computed tomography (CT) revealed an infiltrative shadow. Two separate sputum cultures detected Aspergillus niger. Although we treated the patient with single and combined antifungal agents, the infiltrative shadow worsened. After obtaining sufficient informed consent from the patient, we switched him to an inhaled L-AMB. The infiltrative shadow subsequently improved. The patient has remained well for one year without exacerbation. We herein report the usefulness of inhaled L-AMB and oral VRCZ.

Severe COVID-19 patients complicated with aspergillosis are increasingly reported. We present a histopathological proven case of fatal COVID-19-associated pulmonary aspergillosis (CAPA), due to Aspergillus flavus. This report and existing published literature indicate diagnostic challenges and poor outcomes of CAPA in ICU patients., (© 2021 Wiley-VCH GmbH.)

A 47-year-old Caucasian man on long-standing antifungal therapy for chronic necrotising aspergillosis and a history of recurrent pseudomonas pneumonias presented to the outpatient pulmonary clinic with dyspnoea and chest discomfort for 3 days. A CT angiography of the chest demonstrated angioinvasion from the previously noted left upper lobe cavitary lesion into the left main pulmonary artery, along with new consolidating lesions. Due to the high risk for massive haemoptysis, he was evaluated by thoracic surgery and underwent a successful left pneumonectomy. As invasive pulmonary aspergillosis is associated with high mortality, surgical intervention should always be considered, especially in those who develop extensive disease, despite being on aggressive antifungal therapy. Though minimally described in literature, invasive pulmonary pseudomonas also carries a high mortality risk. In our patient, cultures from the resected lung only demonstrated Pseudomonas aeruginosa ., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

BACKGROUND: Pulmonary TB (PTB) and chronic pulmonary aspergillosis (CPA) are both progressive and debilitating parenchymal lung diseases with overlapping risk factors, symptomatology and radiological findings that often result in misdiagnosis of either disease. METHODS: We undertook a narrative review approach to describe the clinical and radiological manifestations of CPA and PTB and highlight the salient features that differentiate these two closely related maladies. RESULTS: CPA is a frequent complication of treated PTB. In fact, 15-90% of CPA cases occur in patients with residual lung lesions following treatment for PTB. While CPA predominantly affects older patients with underlying lung diseases, both PTB and CPA present with clinically indistinguishable symptoms. Chest imaging findings of cavitation and fibrosis are common to both diseases. However, lymphadenopathy, miliary pattern and pleural effusion are predictive of active PTB, while aspergilloma, pleural thickening and paracavitary fibrosis are more common in CPA. Aspergillus -specific IgG serology has a central role in differentiating PTB (both active and healed) from CPA with a high sensitivity and specificity. CONCLUSION: Aspergillus -specific IgG serology is key in differentiating PTB and PTB relapse from CPA. It may be worthwhile developing clinical predictive scores that can be used in low-income settings to differentiate active TB, post-TB disease and TB+CPA co-infection.

Aspergillus species are ubiquitous, and inhalation of infectious conidia is not so uncommon. With immunosuppression, it can invade adjacent structures and lead to widespread invasive disease. There is no randomized, prospective trial for optimized treatment including the antifungal and surgical approach for aspergilloma. The available literature related to the management of asymptomatic aspergilloma in pre-renal transplant setting is scarce and debatable. Opinion favoring surgery is that it is necessary to eliminate the fungus reservoir before transplantation because of the inadequacy of pharmacological fungus control measures in immunocompromised patients. We present a case of end-stage renal disease that was planned for renal transplantation and during the workup, was detected to have asymptomatic right upper lobe aspergilloma. He underwent surgical resection of the aspergilloma before undergoing successful renal transplantation. In this case report, we will discuss this case and controversies related to its management before undergoing successful renal transplantation.

The coexisting presence of hydatid disease with aspergillus colonization is a rare finding. The 20-year-old presented with symptoms of hemoptysis with past history of tuberculosis. On further evaluation, the patient was diagnosed as a case of aspergilloma and managed conservatively. After one year of presenting with similar complaints, the patient was turned out to be hydatid disease with aspergillus colonization on the basis of clinic-radiological and bronchoscopic evaluation. Till now only a few case reports have been reported. We report a unique case report of a similar presentation.

Fungal infections involving the pituitary gland are rare and can be life threatening. A 75-year-old man with hypertension and diabetes mellitus presented with headache and hyponatraemia. Imaging study showed right upper lung mass, and mass resection showed aspergilloma without tissue invasion on histology. The patient developed visual impairment a few weeks later, and MRI of the brain revealed bilateral sphenoid sinusitis and pituitary invasion. The trans-sphenoidal biopsy confirmed invasive Aspergillus infection. His sphenoidal sinuses were endoscopically debrided, and he was treated with oral voriconazole. Pituitary aspergillosis should be considered in the differential diagnosis in patients with lung aspergilloma with headache and sinusitis. Prompt biopsy and antifungal treatment are important due to the high mortality rate of the infection., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Rationale: Aspergillus infection in patients with suspected ventilator-associated pneumonia remains uncharacterized because of the absence of a disease definition and limited access to sensitive diagnostic tests. Objectives: To estimate the prevalence and outcomes of Aspergillus infection in adults with suspected ventilator-associated pneumonia. Methods: Two prospective UK studies recruited 360 critically ill adults with new or worsening alveolar shadowing on chest X-ray and clinical/hematological parameters supporting suspected ventilator-associated pneumonia. Stored serum and BAL fluid were available from 194 nonneutropenic patients and underwent mycological testing. Patients were categorized as having probable Aspergillus infection using a definition comprising clinical, radiological, and mycological criteria. Mycological criteria included positive histology or microscopy, positive BAL fluid culture, galactomannan optical index of 1 or more in BAL fluid or 0.5 or more in serum. Measurements and Main Results: Of 194 patients evaluated, 24 met the definition of probable Aspergillus infection, giving an estimated prevalence of 12.4% (95% confidence interval, 8.1-17.8). All 24 patients had positive galactomannan in serum ( n  = 4), BAL fluid ( n  = 16), or both ( n  = 4); three patients cultured Aspergillus sp. in BAL fluid. Patients with probable Aspergillus infection had a significantly longer median duration of critical care stay (25.5 vs. 15.5 d, P  = 0.02). ICU mortality was numerically higher in this group, although this was not statistically significant (33.3% vs. 22.8%; P  = 0.23). Conclusions: The estimated prevalence for probable Aspergillus infection in this geographically dispersed multicenter UK cohort indicates that this condition should be considered when investigating patients with suspected ventilator-associated pneumonia, including patient groups not previously recognized to be at high risk of aspergillosis.

Purpose: Pathological data of critical ill COVID-19 patients is essential in the search for optimal treatment options., Material and Methods: We performed postmortem needle core lung biopsies in seven patients with COVID-19 related ARDS. Clinical, radiological and microbiological characteristics are reported together with histopathological findings., Measurement and Main Results: Patients age ranged from 58 to 83 years, five males and two females were included. Time from hospital admission to death ranged from 12 to 36 days, with a mean of 20 ventilated days. ICU stay was complicated by pulmonary embolism in five patients and positive galactomannan on bronchoalveolar lavage fluid in six patients, suggesting COVID-19 associated pulmonary aspergillosis. Chest CT in all patients showed ground glass opacities, commonly progressing to nondependent consolidations. We observed four distinct histopathological patterns: acute fibrinous and organizing pneumonia, diffuse alveolar damage, fibrosis and, in four out of seven patients an organizing pneumonia. None of the biopsy specimens showed any signs of invasive aspergillosis., Conclusions: In this case series common late histopathology in critically ill COVID patients is not classic DAD but heterogeneous with predominant pattern of organizing pneumonia. Postmortem biopsy investigations in critically COVID-19 patients with probable COVID-19 associated pulmonary aspergillosis obtained no evidence for invasive aspergillosis., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2020. Published by Elsevier Inc.)

Rationale: The left internal jugular vein has a higher possibility of anatomical variation than the right side. Therefore, the complication risk during cannulation is expected to be higher., Patient Concerns: A 74-year-old woman was scheduled for elective surgery for left upper lobe wedge resection. We observed an anatomical abnormality at the location of the common carotid artery (CCA) and left internal jugular vein (IJV)., Diagnosis: During the ultrasound, the left IJV was detected at the medial side of the CCA, and this anatomical variation was confirmed by color Doppler ultrasonography. Enhanced chest computed tomography showed that the left CCA ran across the left IJV from medial to lateral at the level of the clavicle., Intervention: A triple-lumen central venous catheter was inserted at the right IJV to avoid complications caused by the anatomical variation., Outcomes: There were no intraoperative or postoperative complications., Lessons: Anesthesiologists should consider anatomical variation during central venous cannulation, especially with the left IJV approach. Because of anatomical variation, ultrasound-guided intervention is highly recommended to prevent procedure-related complications.