Bronchial stub aspergillosis (BSA) is an unusual entity.

Bronchial stub aspergillosis (BSA) is an unusual entity. We report a case presenting hemoptysis four years after right upper lobe resection because of lung cancer. Simple removal of the silk line of junction is most likely the treatment of choice. No additional local or systemic antifungal therapy is needed

The representation of the different clinical forms of Aspergillus infection has expanded continually in the last decade.[1] Tracheobronchial aspergillosis usually has been described in association with invasive pulmonary aspergillosis.[2] Occasionally, the infection may be just limited to the bronchial mucosa, without simultaneous pulmonary infection, as has been reported in a not many immunosuppressed patients with the name of ulcerative or pseudomembranous necrotizing tracheobronchial aspergillosis.[3-5]

Little attention has been paid to colonization of endobronchial silk line of junction and infection of surrounding bronchial granulation tissue by way of Aspergillus as a specific cause of cough and hemoptysis. The existence of bronchial stub aspergillosis (BSA) even has been ignored in novel extensive reviews on endobronchial sutures[6]

CASE REPORT

Three years ago, we visited a 38-year-old man who had mild hemoptysis. He had complained of cough for the previous eight month Four years before, the patient had lung cancer in the right upper lobe, and a lobectomy was performed. The postoperative period was quiet A pathologic diagnosis of epidermoid tumor without invasion of hilar or mediastinal lymph nodes was made. No additional chemotherapy or radiotherapy was administered. Follow-up during the nearest four years did not exhibit any evidence of tumor resort He had been a heavy smoker and gave up smoking after the surgical operation. At the time of physical examination, findings and laboratory data were within normal limits. A chest x-ray film showed the usual changes proper to right upper lobectomy. Cytological examination of three sputum samples gave negative terminates for malignant cells as well as for hyphae. During bronchoscopy a silk line of junction at the bronchial stump was fix There was a small amount of granulation tissue around the line of junction Complete removal of the line of junction and surrounding tissue with standard cupful forceps caused some bleeding that stopped spontaneously. Pathologic examination revealed no tumor nevertheless disclosed inflammatory and necrotic tissue with numerous hyphae showing the morphologic features of Aspergillus (Fig 1) Without any other treatment, the patient improved in a scarcely any days, and he has remained asymptomatic for the last three years. A inferior bronchoscopy, performed one month after the first, revealed a normal appearing bronchial stump

DISCUSSION

Although localized Aspergillus infestation sometimes has been described in lung neoplasms,[7] no evidence of tumor relapse was build in our case. Most knowledge about BSA derives from the experimental and clinical contemplation performed by Sawasaki et al.[8] These authors showed that the incidence of this peculiar manifestation of Aspergillus infection was 15 percent when silk was used as the endobronchial line of junction in pulmonary resection. An extremely high incidence (246 percent) of local inflammation around silk thread also was pointed revealed in contrast with the rarity of of the like kind bronchoscopic findings when the line of junction material was nylon (5.7 percent) The specific tropism of Aspergillus for tissues with poor viability, in spite of pious drainage, already has been reported in near studies.[9,10] Besides local inflammation, it has been stated that the distinctive high capillarity of silk thread favors local infection by means of Aspergillus[8] Interestingly, among the nine cases reported by means of Sawasaki et al,[8] the period from the operation to the attack of disease usually ranged from 6 to 12 months; in and nothing else one case the symptom-free interval was 3 years and 2 months[8] To the best of our knowledge, similar a long latency period as that observ in our case has not been reported.

Silk thread was widely used by means of thoracic surgeons until some years ago, and it has been progressively replaced at newer materials. However, it must be kept in mind that a protracted symptom-free interval, such as that in our case, may flash on the mind in BSA. Unlike most numerous pulmonary manifestations of Aspergillus, BSA usually has been reported in patients with no apparent immunocompromise.[8] Interestingly, BSA has been considered the pathogenic cause of one cases of Aspergillus empyema.[11] Therefore, besides the usual clinical features of cough and hemoptysis directly caused on this entity, lack of exact diagnosis may imply long-term complications in postsurgical patients.

It is worthwhile to emphasize that simple removal of the line of junction is likely to be the therapy of choice in BSA, considering the optimal follow-up in our case with just line of junction removal and the potentially harmful side tenors of many antimycotic therapies. Although Sawasaki et al[8] advocated the administration of topical or systemic antifungal therapy, the inferences of this therapy cannot be validated by means of their own findings since no dominion government group was included in the study

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