Aspergillus niger pneumonia as superinfection in a patient with pulmonary tuberculosis

Abstract

We report a patient with severe cavitary pulmonary tuberculosis and Aspergillus niger superinfection, whose only comorbidity was untreated diabetes mellitus.

A. niger pneumonia was proven by PCR, sequencing and culture of pleural and respiratory secretions. The patient was successfully treated with a four-drug antituberculous regimen, liposomal amphotericin B (up to 5 mg/kg/d) and pleuro-pneumonectomy. Histology of the resected lung revealed destroyed lung tissue with inflammatory cells and fungal conidia. There were large deposits of polarising material, which was found to be calcium oxalate. There was also nodular caseating necrosis bordered by epitheloid cells and connective tissue. Thus, all diagnostic criteria for invasive A. niger infection were met.

Several local risk factors, such as extensive lung damage and tissue acidification, may have favoured superinfection by A. niger. This case highlights the diagnostic value of calcium oxalate crystals in lung tissue and the need for combined antimicrobial and surgical treatment in extensive invasive aspergillosis caused by A. niger.

Zusammenfassung

Wir berichten über einen Patienten mit schwerer kavitärer Lungentuberkulose und einer Superinfektion durch Aspergillus niger. Die einzige Prädisposition bestand in einem unbehandelten Diabetes mellitus.

Die Pneumonie durch A. niger wurde durch PCR, Sequenzierung und Kultur von Pleuraerguss-Flüssigkeit und respiratorischen Sekreten gesichert. Der Patient wurde erfolgreich mit einer antituberkulösen Vierfachtherapie, liposomalem Amphotericin B (bis zu 5 mg/kg/d) und einer Pleuro-Pneumonektomie behandelt. In der Histologie des Lungenresektates zeigten sich ein zerstörtes Lungengewebe sowie eine ausgedehnte Inflammation und typische Konidien. Zudem fanden sich ausgedehnte Ablagerungen von polarisationsoptisch doppelbrechendem Material, Kalzium-Oxalat-Kristallen entsprechend. Ebenso fanden sich noduläre verkäsende Nekroseareale, die von Epitheliodzellen und Bindegewebe umgeben waren. Somit waren alle diagnostischen Kriterien einer invasiven A. niger-Infektion erfüllt.

Die Superinfektion durch A. niger wurde mutmaßlich durch eine Reihe von lokal wirksamen Risikofaktoren wie einer ausgedehnten Lungengewebsschädigung und Gewebesäuerung begünstigt. Unser Fall unterstreicht die diagnostische Bedeutung von Kalzium-Oxalat-Kristallen im Lungengewebe und die Notwendigkeit einer kombinierten antimikrobiellen und thoraxchirurgischen Therapie bei ausgeprägter invasiver Aspergillose durch A. niger.

Publication History

Received: 06 March 2023

Accepted: 14 June 2023

Article published online:
11 September 2023

• References

• 1 Metzger JB, Garagusi VF, Kerwin DM. Pulmonary oxalosis caused by Aspergillus niger. Am Rev Respir Dis 1984; 129: 501-502
• 2 Kimmerling EA, Fedrick JA, Tenholder MF. Invasive Aspergillus niger with fatal pulmonary oxalosis in chronic obstructive pulmonary disease. Chest 1992; 101: 870-872
• 3 Nakagawa Y, Shimazu K, Ebihara M. et al. Aspergillus niger pneumonia with fatal pulmonary oxalosis. J Infect Chemother 1999; 5: 97-100
• 4 Person AK, Chudgar SM, Norton BL. et al. Aspergillus niger: an unusual cause of invasive pulmonary aspergillosis. J Med Microbiol 2010; 59: 834-838
• 5 Osholowu OS, Kak V, Singh H. Pulmonary oxalosis in pulmonary aspergillosis syndrome. Adv Respir Med 2020; 88: 153-156
• 6 Schils R, Altdorfer A, Moerman F. et al. A rare case of invasive pulmonary aspergillosis presenting as organizing pneumonia due to Aspergillus niger in an immunocompetent host. Respir Med Case Rep 2021; 34: 101503
• 7 Trovato L, Calvo M, Migliorisi G. et al. Fatal VAP-related pulmonary aspergillosis by Aspergillus niger in a positive COVID-19 patient. Respir Med Case Rep 2021; 32: 101367
• 8 Okamura K, Noro R, Fujita K. et al. Acute respiratory failure due to Aspergillus niger infection with acute fibrinous and organizing pneumonia: A case report. Respir Med Case Rep 2022; 37: 101641
• 9 Thompson III GP, Young JAH. Aspergillus infection. N Engl J Med 2021; 385: 1496-1509
• 10 Patterson TF, Kirkpatrick WR, White M. et al. Invasive aspergillosis. Disease spectrum, treatment practices, and outcomes. I3 Aspergillus Study Group. Medicine (Baltimore) 2000; 79: 250-60
• 11 Severo LC, Geyer GR, Porto Nda S. et al. Pulmonary Aspergillus niger intracavitary colonization. Report of 23 cases and a review of the literature. Rev Iberoam Micol 1997; 14: 104-110
• 12 Abdel-Rahim AM, Arbab HA. Factors affecting spore germination in Aspergillus niger. Mycopathologia 1985; 89: 75-79
• 13 https://www.umwelt-online.de/regelwerk/cgi-bin/suchausgabe.cgi?pfad=/eu/00_04/04_853c.htm&such=Teile
• 14 Donnelly JP, Chen SC, Kauffman CA. et al. Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Clin Infect Dis 2020; 71: 1367-1376
• 15 Reyes CV, Kathuria S, MacGlashan A. Diagnostic value of calcium oxalate crystals in respiratory and pleural fluid cytology. A case report. Acta Cytol 1979; 23: 65-68
• 16 Molina Boix M, Ortega González G, Salinas Caballero F. et al. [Pulmonary oxalosis caused by Aspergillus niger]. Med Clin (Barc) 1985; 84: 796
• 17 Lee SH, Barnes WG, Schaetzel WP. Pulmonary aspergillosis and the importance of oxalate crystal recognition in cytology specimens. Arch Pathol Lab Med 1986; 110: 1176-1179
• 18 Procop GW, Johnston WW. Diagnostic value of conidia associated with pulmonary oxalosis: evidence of an Aspergillus niger infection. Diagn Cytopathol 1997; 17: 292-294
• 19 Gómez F, Tarín V, Cuadrado M. et al. Tracheal oxalosis associated with Aspergillus niger tracheobronchitis. Eur Respir J 2013; 41: 995-997
• 20 Severo LC, Londero AT, Geyer GR. et al. Oxalosis associated with an aspergillus niger fungus ball. Report of a case. Mycopathologia 1981; 73: 29-31
• 21 Roehrl MH, Croft WJ, Liao Q. et al. Hemorrhagic pulmonary oxalosis secondary to a noninvasive Aspergillus niger fungus ball. Virchows Arch 2007; 451: 1067-1073
• 22 Oda M, Saraya T, Wakayama M. et al. Calcium oxalate crystal deposition in a patient with Aspergilloma due to Aspergillus niger. J Thorac Dis 2013; 5: E174-178
• 23 Kauffman CA, Wilson KH, Schwartz DB. Necrotizing pulmonary aspergillosis with oxalosis. Mykosen 1984; 27: 535-538
• 24 Wiggins J, Clark TJ, Corrin B. Chronic necrotising pneumonia caused by Aspergillus niger. Thorax 1989; 44: 440-441
• 25 Khabir A, Makni S, Ayadi L. et al. Pulmonary oxalosis with necrotizing pulmonary aspergillosis. Ann Pathol 2002; 22: 121-123
• 26 Johnson LB, Kauffman CA. Voriconazole: a new triazole antifungal agent. Clin Infect Dis 2003; 36: 630-637