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Eur J Cardiothorac Surg 2005;27:1132-1133
© 2005 Elsevier Science NL
Letter to the Editor |
Department of Cardiac Surgery, Royal Hospital for Sick Children, Dalnair Street, Glasgow G3 8SJ, UK
Received 28 January 2005; accepted 28 February 2005.
* Tel.: +44 141 201 0269. (E-mail: sgunpat{at}hotmail.com).
Key Words: Aspergillosis • Intralobar sequestration
In the article ‘Pulmonary sequestration and Aspergillosis’, Berna et al. [1] highlight the association between pulmonary sequestration (ILS) and aspergillosis. An increasing number of sequestrations are being reported in adults. Whether this reflects an improved ability to diagnose the lesion, an actual increase in the incidence of the disease or a combination of both, is a matter of debate.
The authors describe four cases of aspergillosis complicating ILS. Given that aspergillosis has the propensity to colonize and infect pre-existing pulmonary cavities such as tuberculous cavities and cavitating neoplasia, it is not surprising that these patients presented with aspergillosis complicating a sequestration. Is this association specific or coincidental?
Aspergillosis is perhaps the commonest fungal infection affecting the lung. Besides HIV, and tuberculosis, did the authors consider other risk factors for fungal infections like diabetes, malnutrition, and immunoincompetence?
All four patients had lesions of the lower lobes, which is in keeping with the predilection of sequestration for the lower lobes. Some of the patients described presented with what is described as obstructive bronchopathy and allergy. It may well have been that these patients had a form of allergic bronchopulmonary aspergillosis. Did the aspergillosis precede or complicate the sequestration?
It is important to identify the anomalous arterial supply in these patients particularly if the sequestration is infected which can lead to dense adhesions. The anomalous vascular supply then becomes difficult to identify and can lead to potentially catastrophic hemorrhage at surgery.
The authors suggest that the finding of an aspergilloma in ILS supports the hypothesis that ILS may be an acquired lesion. The pathogenesis of aspergillosis is still controversial. The formation of ILS begins with the obstruction of lower lobe bronchus complicated with pneumonia. If in conjunction with bronchial obstruction and the chronic pneumonia, an interruption of the arterial supply to the infected portion ensues, then with the parasitisation of the pulmonary ligament artery, an ILS may develop [2].
The authors state that the risk of developing aspergillosis in ILS is not yet established. The risk of developing aspergillosis in ILS would be the same as an aspergilloma developing in any cavitating lesion. The association between aspergillosis and ILS is not specific.
They suggest that investigations for aspergillosis should be included in the diagnostic workup of sequestrations. Given the uncommon incidence of the two pathological processes and the rarity of the combination, the diagnostic yield is bound to be low, unless specific protocols or criteria become available for the investigation of both aspergillosis and sequestration.
What is the role of antifungal medication in these patients?
The authors suggest that a preoperative diagnosis of aspergillosis should be an additional argument for surgery in cases of sequestration. The diagnosis of sequestration is in itself an indication for surgery, with or without aspergillosis. No additional argument for surgery is required. Rather, the finding of a sequestration should constitute an indication for surgery in a patient with aspergillosis.
References
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