Invasive pulmonary aspergillosis: A rare complication after microwave ablation

Figures & data

Figure 1. (A) PET-CT image from case 1 showing a single peripheral lesion, 40 × 38 mm, in the superior segment of the left lower lobe and with high FDG uptake before MWA. (B) CT scan showing a drainage tube placed in the pleural cavity and microwave antennas used for MWA. (C) At 10 days after tumour ablation, the ablated area, 55 × 50 mm, displaying GGO and mild pleural effusion. (D) At 18 days after tumour ablation, the ablation zone has been replaced by a large thin-walled cavity containing a mass of irregular consolidation with an air crescent sign. (E) Macroscopic appearance of expectoration. (F) Photomicrograph of expectoration revealing numerous Aspergillus hyphae (×40, haematoxylin and eosin staining). (G) A contrast-enhanced CT scan at 7 weeks after MWA showing a thin-walled cavity with a smooth lining and fistula formation between the cavity and left inferior lobar bronchus. (H) An enhanced CT follow-up scan at 6 months after MWA showing gradual involution of the cavity.

Figure 2. (A) A CT image from case 2 showing an isolated peripheral lesion of 36 × 35 mm located in the anterior segment of the right upper lobe. (B) MWA was performed with a mild pneumothorax. (C) A CT scan showing a minor pneumothorax and ipsilateral subcutaneous emphysema 3 days after MWA. (D) A CT scan depicting a flake of uneven and faveolate high-density shadow 3 weeks after MWA. (E) CT scan at 6 weeks after MWA showing an uneven thick-walled cavity with an irregular luminal surface, containing an air–fluid level and a beaded consolidation. (F) A drainage tube placed into the cavity under CT guidance.

Figure 3. (A) Enhanced CT and MRI scan from case 3 showing a peripheral neoplasma 35 mm in diameter adjacent to an oblique fissure in the left lower lobe. (B) MWA was performed at a power of 70 W for an accumulated total time of 12 min. (C) CT follow-up scan at 48 h after MWA showing a GGO-like reaction band around the lesion encompassing the entire tumour. (D) CT scan on day 10 after MWA showing the stable GGO ablation zone. (E) Enhanced CT scan at 32 days after MWA showing a larger pneumothorax and atelectasis. (F) Follow-up CT scan at 2 months after MWA showing the formation of a bronchopleural fistula within the MWA cavitation that abutted the visceral pleura.

Table 1. Patient characteristics.

Case no.	Gender	Age (years)	Co-morbidity	Lung function (FEV1, DLCO)	Smoking index	Site of tumour	Tumour size (mm)	Lymph node metastases	Distant metastasis	Stage
1	Male	63	COPD (emphysema)	39.1%, 13.1%	1350	Left lower lobe	40	no	no	Ib
2	Male	65	COPD (emphysema), cardiac/cerebro- vascular disease	44.2%, 66.7%	1200	Right upper lobe	36	no	no	Ib
3	Female	61	CHB (active phase), mild malnutrition	122.2%, 59.4%	None	Left lower lobe	35	no	no	Ib

Table 2. Ablation, microbiology and treatment characteristics for the three cases.

Case no.	Number of antennas	Number of ablation sites	Total time of ablation (min)	Power of ablation (W)	Aspergillus species	Co-infection	Antifungal drug	Adjuvant therapy	Outcome
1	2	4	15	70	Aspergillus fumigates	Acinetobacter baumannii, Staphylococcus aureus	Voriconazole	Postural drainage Intracavitary lavage	Cure, alive
2	2	2	14	70	Aspergillus fumigates	None	Voriconazole	Intracavitary lavage	Cure, alive
3	2	3	12	70	Aspergillus fumigates	Klebsiella pneumoniae	Voriconazole	Closed drainage of pleural cavity	Death

Table 3. Level of certainty for the diagnosis of IPA for the three cases.

Case no.	Host factors	Clinical manifestations (imageology)	Mycological positive findings (Aspergillus fumigates)	Serological β-D-glucan, galactomannan	Certainty of IPA
1	Primary lung cancer, COPD (emphysema)	Thin-walled cavity within an area of irregular consolidation (an air crescent sign)	Histopathological examination of the expectoration	Positive	Definitive
2	Primary lung cancer, COPD (emphysema)	Uneven thick-walled cavity within an area of beaded consolidations	Cavity lavage fluid cultures in sterile conditions	Positive	Definitive
3	Primary lung cancer, chronic hepatitis B, malnutrition	Delayed pneumothorax, a bronchopleural fistula, pleural effusion and atelectasis	More than twice from sputum smears and cultures	Positive	Probable