VATS Treatment for Pulmonary Aspergilloma in a Patient With Lupus

Patients with systemic lupus erythematosus (SLE) may suffer from complications, which are important causes of morbidity and mortality. The immunodepression of the systemic pathology itself, combined to corticosteroids and immunosuppressive treatments, are responsible for infections (1, 2).

A 27-year-old man was hospitalized in the thoracic surgery department with a symptomatology of hemoptysis that started three months before his admission. He was diagnosed with SLE in 2010 with articular and hematological manifestations. He was receiving a long-term corticotherapy and hydroxychloroquine. His medical history included two episodes of pulmonary tuberculosis in 2009 and 2015, both well-treated with antitubercular antibiotics. He reported not smoking, drinking alcohol, or having any other toxic habits. On physical examination, the body mass index was 13.5. Sputum test for tuberculosis was negative. Anti-Aspergillus fumigatus IgG level was elevated (75 U/mL) and indirect Aspergillus hemagglutination test was 1/160. A computed tomography scan showed an aspect of aspergilloma on cystic bronchial dilatation cavity filled by heterogeneous density material, which seemed to communicate with the bronchial tree by a drainage bronchus.

He was admitted for a lobectomy. An exploratory video-assisted thoracoscopic surgery (VATS) was initially done: multiple adhesions were identified, particularly between the upper lobe and the chest, around the diaphragm and aorta. Adhesiolysis was performed with a thermofusion clip. Vessels and bronchus to the left upper lobe were carefully dissected and individually ligated with endoscopic devices to free the lobe. The operative piece measured 13 x 6 x 4 centimeters. Its opening showed a cavitary, brown-red mass containing friable material. Histological examination showed a cystic wall lined with fibrino-leukocyte material and foamy histiocyte plaques whose light contained numerous aspergillary filaments. Postoperative chest x-ray showed no pleural effusion, and the patient was discharged three days after his surgical operation.

Pulmonary aspergillosis is a risk that may complicate any immunocompromising disease or immunosuppressive therapy (1). Moreover, it can be grafted in a tuberculous sequelar cavity. In patients with systemic diseases, aspergillosis is favored both by the systemic pathology itself and by a disruption of macrophage and neutrophilic functions induced by corticosteroid and/or immunosuppressive treatments. The risk of fungal infection increases with the dose and duration of corticosteroids (2).

Open thoracotomy used to represent the main approach technique, with lobectomy as the most common procedure (3). These surgical procedures are invasive and require an extended postoperative hospital stay. They are not recommended in patients with low pulmonary function reserves. A VATS procedure shows significant benefits over an open thoracotomy: it is less invasive, involving only a couple of small incisions. The opening of the ribs is not necessary, which considerably reduces pain. The length of stay is shorter with fewer postoperative complications, and the long-term results are at least as good or better (4). It also offers excellent visualization when taking down adhesions in the apex of the chest thanks to the mobile camera managed by the surgeon (4).

References

1. Gonzalez-Crespo MR, Gomez-Reino JJ. Invasive aspergillosis in systemic lupus erythematosus. Semin Arthritis Rheum. 1995;24(5):304-314.
2. Kim HJ, Park YJ, Kim WU, Park SH, Cho CS. Invasive fungal infections in patients with systemic lupus erythematosus: experience from affiliated hospitals of Catholic University of Korea. Lupus. 2009;18(7):661-666.
3. Danner BC, Didilis V, Dörge H, Mikroulis D, Bougioukas G, Schöndube FA. Surgical treatment of pulmonary aspergillosis/mycosis in immunocompromised patients. Interact Cardiovasc Thorac Surg. 2008;7(5):771-776.
4. Parker KL, Zervos MD, Darvishian F, Bizekis CS. Video-assisted thoracoscopic lobectomy for pulmonary aspergilloma after life-threatening hemoptysis in a patient with lupus. Ann Thorac Surg. 2010;89(1):291-292.