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Médecineetmaladiesinfectieuses45(2015)128–132
Original article
Chronic pulmonary aspergillosis: A frequent and potentially severe disease
L’aspergillose pulmonaire chronique : une pathologie fréquente et potentiellement grave
H. Benjelloun
a,∗, N. Zaghba
a, N. Yassine
b, A. Bakhatar
a, M. Karkouri
b, M. Ridai
c, A. Bahlaoui
baServicedesmaladiesrespiratoires,hôpitalIbnRochd,Casablanca,Morocco
bServiced’anatomiepathologique,hôpitalIbnRochd,Casablanca,Morocco
cServicedechirurgiethoracique,hôpitalIbnRochd,Casablanca,Morocco Received5November2014;receivedinrevisedform6January2015;accepted29January2015
Availableonline18February2015
Abstract
Introduction.–Chronicpulmonaryaspergillosisisapulmonaryfungalinfectionwithvariouspresentationsthatcanoccuronapre-existingcavity, oftenasequeloftuberculosis.Theobjectiveofourstudywastoreportthediagnosticandtherapeuticmanagementofpulmonaryaspergillomain ourstructure.
Patientsandmethods.–Weretrospectivelystudied81casesofpulmonaryaspergillomahavingoccurredintherespiratorydiseasesunitofthe CasablancaIbnRochdhospital,over11years.
Results. –Weincluded48maleand 33femalenon-immunocompromisedpatients,withanaverageageof 51years(27–75).Ahistoryof tuberculosiswasrecordedin78cases.Hemoptysiswastherevealingsymptomin73cases.Acharacteristic“bell-like”imagewasobservedin25 cases.Theserologicalresultswerepositiveforaspergillusin54cases.Thetreatmentwassurgicalin50casesandmedicalin24cases.Fivepatients died.
Discussion. –Asignificantnumberofpulmonaryaspergillomacases wererecordedinourstudy,occurringmostfrequentlyonsequelsof tuberculosis.Thisdiseaseiscurrentlycommonincountrieshighlyendemicfortuberculosis;earlyandadequatemanagementisrequired.
Conclusion.–Aspergillosisisafrequentandpotentiallyseverediseaseoccurringonpre-existinglesions,mostofteninourcontextsequels oftuberculosis.Surgicalresectionisthereferencetreatmentbutisthecauseofasignificantmorbidityandmortality.Preventivemeasuresare mandatory.
©2015ElsevierMassonSAS.Allrightsreserved.
Keywords: Aspergilloma;Mycosis;Sequeloftuberculosis;Hemoptysis Résumé
Introduction.–L’aspergillosepulmonairechroniqueestuneinfectionmycosiquepulmonairequipeutprendredifférentsaspectsetsurvenirsur unecavitépréexistante,leplussouventséquellaired’unetuberculose.L’objectifdecetravailestderapporterlapriseenchargediagnostiqueet thérapeutiquedesaspergillomespulmonaireschezdespatientsnonimmunodéprimésdansnotrestructure.
Patientsetméthodes.–Nousrapportonsuneétuderétrospectiveportantsur81casd’aspergillomepulmonairecolligésauservicedesmaladies respiratoiresducentrehospitalieruniversitaireIbnRochddeCasablanca,surunepériodede11ans.
Résultats. –Il s’agissaitde48hommeset33femmesnon immunodéprimés.Lamoyenne d’âgeétait de51ans(27–75). L’antécédentde tuberculoseétaitnotédans78cas.L’hémoptysieétaitlesymptômerévélateurdans73cas.L’imagecaractéristiqueengrelotétaitrelevéedans 25cas.Lasérologieaspergillaireétaitpositivedans54cas.Letraitementétaitchirurgicaldans50casetmédicaldans24cas.Cinqdécèsétaient rapportés.
Discussion.–Àtraverscetteétude,unnombreimportantd’aspergillomepulmonaireétaitrecensé,survenantpourlaplupartsurdesséquelles detuberculose.Cetteaffectionest,àcejour,fréquentedanslespaysàforteendémietuberculeused’oùlanécessitéd’unepriseenchargeprécoce etbienadaptée.
∗Correspondingauthor.
E-mailaddress:hananebenj@yahoo.fr(H.Benjelloun).
http://dx.doi.org/10.1016/j.medmal.2015.01.014
0399-077X/©2015ElsevierMassonSAS.Allrightsreserved.
Conclusion.–Lagreffeaspergillaireestunepathologiefréquenteetpotentiellementgravesurvenantsurdeslésionspréexistantesleplussouvent tuberculeuse.Lachirurgied’exérèsedemeurelathérapeutiquederéférencemaislacaused’unemorbimortaliténonnégligeable.Lesmesures préventivesrestentindispensables.
©2015ElsevierMassonSAS.Tousdroitsréservés.
Motsclés:Aspergillome;Mycose;Séquellesdetuberculose;Hémoptysie
1. Introduction
Pulmonary aspergillosis is an opportunistic pulmonary mycosis pulmonary fungal infection with various presenta- tionsdependingontheunderlyingcondition andthe patient’s immune status. Pulmonary aspergilloma is the development ofAspergillushyphaeinpre-existingcavities,usuallysequels of tuberculosis [1–3]. It can present as simple pulmonary aspergilloma or chronic cavitary pulmonary aspergillosis (CCPA)[4].Surgicalresectionistheonlytrulycurativetreat- ment and should be planned as soon as possible to prevent sometimes-fatalinfectiousandhemorrhagiccomplications.The severityofthediseaseisrelatedtoitsmorbidityandmortality [5].Theobjectiveofthisstudyistodescribetheepidemiological, clinical,diagnosticandtreatmentofthisfungus.
2. Patientsandmethods
Weconductedaretrospectivedescriptivestudyof81casesof pulmonaryaspergillomacollectedfromAugust2003toSeptem- ber 2014, in the respiratory diseases unit, at the Casablanca Ibn Rochd Teaching hospital. We selected the records of allHIV-negativenon-immunocompromisedpatientswhowere diagnosedwithpulmonaryaspergillomaaccordingtoradiolog- ical,clinical,and/orbiological,and/orhistologicaldata.
Aninformationsheetwasstudiedforeachpatient.Itincluded epidemiological(age,gender),clinical(underlyingconditionor clinicalhistory),andlaboratory(chestimaging,bronchoscopy, aspergillusserology)data.Thehospitalmorbidityandmortality, aswellastheshortandlong-termoutcomewerealsoconsidered.
Thedefinitionofaspergillusinfectionisnotclearlydefined and many entities have been described with various names.
TheclassificationoftheInfectiousDiseasesSocietyofAmer- ica(IDSA)distinguishessimplepulmonaryaspergilloma(SPA) fromchronicpulmonaryaspergillosis(CPA)[6].
The latter is classified as: chronic cavitary pulmonary aspergillosis (CCPA), former complex aspergilloma; chronic necrotizing pulmonary aspergillosis (CNPA); and chronic fibrosingpulmonaryaspergillosis (CFPA),withspecificdiag- nosticcriteria.
This classification divides aspergilloma into 2 categories:
SPA and CCPA. [6] SPA is a parenchymal cavity with well definededgesevolvingwithoutassociatedpleuralparenchymal abnormalities[2].CCPAisdefinedastheoccurrenceofmultiple cavities that may or may not contain an aspergilloma, asso- ciatedwithpulmonary andsystemic symptoms, andelevated inflammatorymarkers[6–8].
Table1
Clinicalpresentationofpulmonaryaspergillomacases.
Présentationcliniquedescasd’aspergillomespulmonaires.
Number Percentage(%)
Historyoftuberculosis 78 96.3
Delaybetweenonsetoftuberculosis andaspergillosis
2–10 32 39.5
10–20 43 53.1
20–23 6 7.4
Hemoptysis 73 90
Dyspnea 56 69.1
Chronicbronchorrhea 27 33.3
Thoracicpain 30 37
Wasting 19 23.4
Fever 12 14.8
OurseriesisanillustrationandadescriptionofAPCCina non-immunocompromisedpopulationwithahighprevalenceof tuberculosis.
3. Results
Forty-eight male and 33 female patients were diagnosed withpulmonaryaspergillomaduringthestudyperiod.Theaver- ageagewas51years(27to75years).Seventy-eight(96.3%) patients hadahistoryof treatedpulmonarytuberculosis. The averagedelaybetweentheonsetoftuberculosisandaspergillo- siswas12.87years(2to23years).Eighteen(22.2%)patients were smokersand4 of thesepresented withchronicobstruc- tivepulmonarydisease(COPD),and4(5%)patientspresented withwell-controlled non-insulindependentdiabetes.Noshort or long-term oral or inhaled corticosteroid therapy was doc- umented. The reasons for consulting were: hemoptysisin 73 (90%)cases(Table1),withanaveragedelaysincetheonsetof symptomsof3months(2daysto7months).Theclinicalexami- nationrevealedaretractedhemithoraxin11(13.6%),stertorous breathing in 72 (89%) patients, andwheezing in28 (34.5%) patients.
Thoracicimaging(Table2),including X-raysandCTscan performed in every cases, revealed pleural thickening in 38 (47%)patients,cavitaryimagein26(32%)patients,andachar- acteristic “bell-like”imagein25 (31%) patients.The lesions werepredominantintheupperlobes,74(91.3%)patients.
Laboratorytestsresultsrevealedanacceleratedsedimenta- tionratein28(34.5%)patients,hypochromicmicrocyticanemia in17(21%)patientswitharangeof6.4to11.1g/dL,andleuko- cytosiswithapredominanceofPNNin13(16%)patientswith
Table2
Thoracicimagingofpulmonaryaspergilloma.
Imageriethoraciquedesaspergillomespulmonaires.
Number Percentage(%)
Pleuralthickening 38 47
Imageofcavities 26 32.1
“Bell-like”image 25 30.8
Lungnecrosis 23 28.4
Uncomplicatedpulmonaryaspergilloma 8 9.8 Chronicpulmonaryaspergilloma 73 90.2
Superiorlobes 74
Rightside 62 91.3
Imageofcavities 26 76.5
arangeof9,700to14,500cells/mm3,withoutneutropenia,con- trolled by the prescription of empiric antibiotic therapy. The cytobacteriologicaldirectexaminationofsputum,performedin 15(18.5%)patients,wasnegative.Aflexiblebronchoscopy,per- formedinallourpatients,revealedendobronchial bleedingin 20(24.7%)patients,aspergillosismycetomain4(5%)patients, abronchialinflammatoryconditionin45(55.5%)patients,and wassubstantiallynormalin5(6%)patients.Aspergillusfumi- gatuswasisolatedinthebronchialaspirateof9(11%)patients.
Screening for the Koch bacillus by direct examination and cultureofsputumandbronchialaspiratewasnegativeinevery case.TheHIVserologywasnegativeineverycase,aswellas thehydatidserologyperformedin8(9.8%)patients,allingood condition,fromruralareas,presentingwithhistologicallycon- firmedSPA.Theaspergillusserologyperformedinallpatients was positivein 54(66.6%)cases. It was performed withthe immuno-electrophoresistechnique(IEP)in62(76.5%)patients, withapositivethreshold>3precipitationarcs,andwiththepas- sivehemagglutinationtechniqueintheremainingpatients,with apositivethreshold>1/320.
Thediagnosisofpulmonaryaspergillomawasmadeforall patients according toradiological aspect, association of sug- gestiveradiologicalsignsandserologypositiveforAspergillus, mycological samples, or postoperative histological findings, after ruling out some differential diagnoses mimicking pul- monary aspergilloma, including ruptured pulmonary hydatid cyst,atubercularcaseousfocus, atypicalmycobacteriosis,an excavatedlungtumor,etc.(Table3).
Thetreatmentwassurgeryin50(61.7%)cases;lobectomy wasperformedin27(54%)cases,pneumonectomyin13(26%) cases,segmentectomyin8(16%)cases,andcavernostomyin2 (4%)cases.
Table3
Elementsofpositivediagnosisofpulmonaryaspergilloma.
Élémentsdudiagnosticpositifdesaspergillomespulmonaires.
Number Percentage(%)
Typical“Bell-like”image 25 30.8
SerologypositiveforAspergillus fumigatus
54 66.6
IsolationofAspergillusfumigatusin bronchialaspirationfluid
9 11
Histology 50 61.7
Anexclusivelymedicaltreatmentbasedonitraconazolewas prescribed in24(29.6%)patientspresentingwithCPAforan averageof7months.Thistherapywasrecommendedforinop- erablepatients (severely alteredlungand/orcardiac function, and/orextentoflesions).Sevenpatientsrefusedanytreatment afterhemoptysiswasstoppedandwerelosttofollow-up.
TheaspergillusinfectionwasclassifiedasSPAin8(9.8%) patients,2 ofthesewerediabetic,theclinicalsymptomswere mild,thetreatment wasexclusivelysurgical,andtheoutcome was good withno recurrenceof hemoptysisafter an average follow-upof 2 yearsand4 months.Aspergillosiswas ranked CPAinotherpatientswhoseclinicalsymptomsweremoresevere and42(57.5%)patientsunderwentsurgery.
ThepostoperativeoutcomeofpatientspresentingwithCCPA, formerly knownas complexaspergilloma,was good,withno recurrenceofhemoptysisin35(83.3%)cases,includingfor2 diabetic patients, afteran averagefollow-upof4 yearsand2 months.Fourpatientspresentedwithrecurrenceofhemoptysis after6to24postoperativemonthsandadiagnosisofbacterial superinfectionoftuberculosissequelswasmade.Threepatients diedpostoperatively,allpresentingwithCOPDandCCPA.
The outcome ofpatients treatedwithantifungalsonlywas marked by the recurrence of hemoptysis in 12 (50%) cases.
This couldbe explainedby theunavailability oftreatment in ourcontextandthe extentoflesions.Twopatients presenting withnon-operatedCPAdiedfromsuddenhemoptysis.
4. Discussion
Aspergillosisisoneofthemostfrequentopportunisticpul- monarymycoses. Theintracavitaryaspergillomaisbyfar the mostcommonpresentation.Aspergillusfumigatusisthespecies mostoftenimplicatedinhumandisease,intemperatecountries.
Itisresponsiblefor80to90%ofpulmonaryaspergillosiscases [1,2,9,10].
Histologically,theaspergillomaisasaprophyticproliferation ofaspergillussporesorganizedasinadensemycelialfelting,or
“mycetoma”withinapreformedcavity[9,11,12]thatisoftena sequeloftuberculosis[3,8,13–15].
Thisinfectionwasobservedin96.3%ofourpatients.This rate is comparable to the literature data, 71.1% of cases as reportedbyChenetal.[15],79.4%byZaitetal.[2],oreven 100%byAdeetal.[5].
Conversely, 11to17% ofpost-tuberculouscavities canbe complicated by aspergilloma [7,12,16].This highpercentage couldbeexplainedinourstudybythesusceptibilityofyoung Moroccanmalepatientstotuberculosisinfection.Thisdiseaseis stillcommoninareasofhighTBendemicitywherethepandemic HIVinfectionhelpedtoincreasethespreadofthisdisease.
However,anyparenchymalcavityislikelytobecomplicated byaspergillosis,includingbronchiectasis,bullousemphysema, andsarcoidosis.Otherconditionsmayalsobecomplicatedby aspergillosis such as pneumoconiosis, fibrosis of ankylosing spondylitis or scleroderma, excavated lung cancer, bacterio- logicallysterilizedlungabscess,pulmonaryinfarctionsequels, cysts,sequesters[2,3,8,10,16–19].
Pasquieretal.reportedacaseofpulmonaryaspergillomain apatientpresentingwithseverethalassemia[19].Hemoptysis remainsthehallmarkofpulmonaryaspergillomaandisreported in50to95%ofcases,accordingtotheauthors[8,9,14,15,20,21].
Thisiswhatwasobservedinourserieswhere90%ofour patients consulted for hemoptysis.That said,the recruitment ofpatientsinourpneumologydepartmentprobablyexplainthe highrateofhemoptysisrevealingtheaspergillusinfection.This infectionisoftenrecurrent,sometimesabundant,andlifethreat- ening[7,20].Othernonspecificsignsmaybeobservedsuchas cough, sputum,chest pain, anddyspnea [3,22].Chronic pul- monaryorsystemicsymptomslastingformorethan3months suggestCPA[4,8].Theaspergillomaisdiscoveredduringsys- tematicX-rayscreeningin10to30%of cases[9].ChestCT isthefirst-lineexaminationforthepositivetopographicdiagno- sis,tolookforotherlocations,andthemonitoringoflesions[9].
ItalsoallowsdiscriminatingbetweenSPAandCPAor CCPA [1,3,9,22–24].Thecharacteristicimageisacavitycontaining a rounded or oval mass, well defined, dense, and homoge- neous,declive, andmobile, whichmay containcalcifications [3,9,11,13,14]. The surrounding pleura is thickenedand may bethe earliestsign[6].Whenthemycelial massislarge, the
“meniscussign”canbe observed. Whenthe massissmall, a
“bell-like”imagecanbeobserved,typicaloftheaspergilloma.
Otheratypicalaspectsmaybeobservedleadingtomisdiagnosis as lungabscess,cavitarycarcinoma,or rupturedhydatidcyst [3,7,11,25,26].
The aspergilloma is usually located in the upper lobes [7,8,14],asreportedbyMimounietal.[27]in79.1%ofcases andinourstudyin91.3%ofcases.Thecharacteristic“bell-like”
imagewasobservedinrespectively66% and30.8%of cases comparedtoonly12.8%asreportedbyZaitetal.[2].Thispref- erentialtopographyisrelatedtotuberculosisthatusuallyaffects theupperlobes[9,22].Theaspergillomaisoftenunique,some- timesmultifocalandbilateral[9,27].Bronchoscopyisrequired.
Itallows:rulingoutsomedifferentialdiagnoses,includinglung tumors;locatingthesourceofbleeding;visualizeanaspergillus mycetoma,performingmycologicalandhistologicalsamplings for diagnostic purposes. Some authors haveeven used it for therapeuticpurposes,asfortheintrabronchialadministrationof amphotericin[28].Serodiagnosisisakeycontributorforthepos- itivediagnosisofaspergilloma[8].Italloweddiagnosing66.6%
ofpatientsinourseries,apercentageclosetothe63%reported byCaidietal.[21]andslightlylowerthanthe75.86%reported byalAde.[5].
However,serologymaybefalselynegativein5 to10% of cases,duetothedeathofthefungus, toaluminalbloodclot, tocasesof aspergillomarelatedtootherfungi,incaseof cor- ticosteroid therapy, or to dysfunction of the T cell response inimmunocompromised patients[21,29,30].Thedetectionof serumgalactomannanantigenhasagoodsensitivityfortheearly detection of invasive aspergillosis, especially in hematologi- calmalignancies[6].Theisolation ofAspergillusoniterative samples (sputum, endobronchial aspiration) is an additional but inconstant argument for the diagnosis in 50% of cases [5].
Thepathologicalexaminationofthesurgicalspecimenmay helpcorrectthepreoperativediagnosisandprovethediagnosis formostpatients[5].
Finally, the diagnosis of pulmonaryaspergilloma is based on a setof clinical, radiological, endoscopic, biological,and possiblyhistologicalelements[17].Theoutcomemaybeaspon- taneous resolutionin7 to10% of cases, or stabilizewithout complicationsin 25%of cases[9,16,20].However, theprog- nosis remains severe given the high risk of bleeding, which canbeexplainedbylocalinvasionofthecavity’sparietalves- sels, mechanical irritation of vascularization exposed in the cavity, the presence of hemolyticendotoxins released by the fungus, or the alleged superimposedacute bacterial infection [3,31].The deathrate attributedtohemoptysisrangesfrom2 to14%or30% dependingontheseries[20].In patientswith specific risks, chronic lung superinfection may lead to local parenchymal necrosis, hence the term of chronic necrotizing aspergillosisorsemi-invasiveaspergillosis[2,17,25].Thetreat- mentofaspergillomaiscontroversialandnon-consensual[3,15].
TheIDSArecommendsasthefirstindicationeithernotreatment or surgical resection,incase of SPA [6].According tosome authors,althoughitisgenerallyacceptedthatitistechnically difficult[7],surgicaltreatmentisconsideredasstandardofcare incaseofpersistenthemoptysisortopreventseriousinfectious and hemorrhagic complications [6,9,16,31–33]. Conservative surgerywitha minimally invasive approachcanbe proposed for simplesmallaspergilloma withaperipherallocationwith betterpostoperativeresults[1,15,20].
However,accordingtotheauthorsofnumerousretrospective surgicalseries,surgerycomeswithasignificantmortalityand morbidity[3,34,35].Threedeathswerereportedpostoperatively inourseries.
Cavernostomycombined withthoracoplastycould be pro- posed. However, this technique remains controversial and requiresmoretesting[1,3,15,36].Bronchialarteryembolization allowsimmediatelytreatingseverehemoptysismostofthetime, andpreparingthepatientforapossiblesurgery[1,7,21,31].
In complex presentations or CCPA, short-term antifungal therapywouldbethebesttreatmentaccordingtotheIDSA,given the impaired immune status and the operative complications often associated [6].Nevertheless, someteams suggestusing plannedsurgerywithausualapproach.
Asystemicantifungaltherapy[9,15,34,35],orbyCTscan guidedintracavitaryinjections [1,21,31],does notseemtobe sufficientlyeffectiveforthisindication,intermsofradiological improvement,mycologicalsterilization,orcontrolofhemopty- sis.However,thesystemicuseofantifungalswassuggestedin therecommendationsofexpertstotreatcomplexaspergilloma, perioperativelyorexclusivelyforinoperablepatients [6,9,20].
Antifungal chemotherapy with itraconazole, voriconazole,or possiblyposaconazole,offerspotentialtherapeuticbenefitswith relatively minimal risk [6,37]. Their action remains undoc- umented for SPA, itraconazole having a better intracavitary distribution[6].Radiationtherapyhasalsogivengoodresultsas alastresortforpatientswiththreateninghemoptysisormultiple locations[1].
5. Conclusion
Pulmonaryaspergillosisis aseveremycosisbecause ofits life-threatening bleeding complications. It grows more fre- quentlyinacavitysequeloftuberculosis,afrequentinfection incountrieswithahightuberculosisendemic.Thisstressesthe importanceofpreventionandofanearlyandadequatemanage- mentofallTBcases.
Contributionofauthors
H. Benjelloun: study design and implementation, data processingandanalysis,draftingofthearticle.
N.Zaghba,N.Yassine,A.Bakhatar,M.Karkouri,M.Ridai, A.Bahlaoui:finalapprovalofthesubmission.
N.Yassine:criticalproofreadingleadingtosignificantmod- ifications.
Disclosureofinterest
The authorsdeclare that theyhave noconflictsof interest concerningthisarticle.
References
[1]MarghliA,ZairiS,OsmenM,OuerghiS,BoudayaMS,AyadiA,etal.
Placedelachirurgieconservatricedansl’aspergillomepulmonaire.Rev MalRespir2012;29(3):384–90.
[2]ZaitH,HamriouiB.Aspergillomepulmonaire:àproposde39cas.JMycol Med2011;21:138–41.
[3]MoodleyL,PillayJ,DhedaK.Aspergillomaandthesurgeon.JThoracDis 2014;6(3):202–9.
[4]DenningDW, RiniotisK,DobrashianR,SambatakouH.Chroniccav- itary and fibrosing pulmonary and pleural aspergillosis: case series, proposednomenclaturechange,andreview.ClinInfectDis2003;37(Suppl 3):S265–80.
[5]AdeSS,TouréNO,NdiayeA,DiarraO,DiaKaneO,DiattaA,etal.Aspects épidémiologiques,cliniques,thérapeutiquesetévolutifsdel’aspergillome pulmonaireàDakar.RevMalRespir2011;28(3):322–7.
[6]WalshTJ,AnaissieEJ,DenningDW,HerbrechtR,KontoyiannisDP,Marr KA.Treatmentofaspergillosis:Clinicalpracticeguidelinesoftheinfec- tiousdiseasessocietyofAmerica.ClinInfectDis2008;46:327–60.
[7]Maheshwari V, Varshney M, Alam K, Khan R, Jain A, Gaur K, etal.Aspergillomalungmimickingtuberculosis.BMJCaseRep2011, http://dx.doi.org/10.1136/bcr.04.2011.4051.
[8]HopeWW,WalshTJ,DenningDW.Theinvasiveandsaprophyticsyn- dromesduetoAspergillusspp.MedMycol2005;43(suppl1):S207–38.
[9]Camuset J, LavoléA, Wislez A,Khalil M, Bellocq A,Bazelly AB, etal.Infectionsaspergillairesbroncho-pulmonairesdusujetnonimmun- odéprimé.RevPneumolClin2007;63(3):155–66.
[10]Smahi M, Serraj M, Ouadnouni Y, Chbani L, Znati K, Amarti A.
Aspergillomaincombinationwithadenocarcinomaofthelung.WorldJ SurgOncol2011;9:27.
[11]YasudaM,NagashimaA,HaroA,SaitohG.Aspergillomamimickinga lungcancer.IntJSurgCaseRep2013;4(8):690–2.
[12]LeeSH,LeeBJ,JungDY,KimJH,SohnDS,ShinJW,etal.Clinical manifestationsandtreatmentoutcomesofpulmonaryaspergilloma.Korean JInternMed2004;19:38–42.
[13]MamaN,DhifallahM,BenAichaS,KadriK,ArifaN,HasniI,etal.
Imagerietomodensitométriquedeslésionspulmonairesexcavées.Feuill radiol2014;54:69–83.
[14]VishakKA,YogithaAP,PreetamAP,AnandR,NaikUB.Ararecaseof calcifiedpulmonaryaspergillome.LungIndia2014;31(1):79–81.
[15]Chen QK, Jiang GN, Ding JA. Surgical treatment for pulmonary aspergilloma:a35-yearexperiencein theChinesepopulation. Interact CardiovascThoracSurg2012;15(1):77–80.
[16]FreymondN,LeLochJB,Devouassoux G,Harf R,RakotomalalaA, PachecoY.Uncasd’aspergillomeassociéàunebronchiteaspergillaire traitésparVoriconazole.RevMalRespir2005;22(5Pt1):811–4.
[17]PaleironN,PegorieA,QuéréG,AndréM,NataliF,GrassinF.Conduite à tenir devant une lésion excavée du poumon. Rev Pneumol Clin 2010;66(2):145–53.
[18]RakotosonJL,VololontianaHMD,RaherisonRE,AndrianasoloRL,Rako- tomizaoJR,RakotohariveloH,etal.Volumineuxaspergillomedéveloppé auseind’unelésiondefibrosepulmonairesecondaireàunesclérodermie.
RevPneumolClin2012;68(1):31–5.
[19]PasquierF.L’aspergillomepulmonaire:unecomplicationpossibledela drépanocytose.RevMedInterne2006;27:257–65.
[20]PagèsPB,AbouHannaH,CaillotD,BernardA.Placedelachirurgiedans lesmaladiesaspergillairesetautresmycosespulmonaires.RevPneumol Clin2012;68(2):67–76.
[21]CaidiM,KabiriH,AlAzizS,ElMasloutA,BenosmanA.Chirurgiedes aspergillomespulmonaires:sériede278cas.PresseMed2006;35(12Pt 1):1819–24.
[22]KimYT,KangMC,SungSW,JooHyunKimJH.Goodlong-termoutcomes aftersurgicaltreatmentofsimpleandcomplexpulmonaryaspergillome.
AnnThoracSurg2005;79:294–8.
[23]MassardG.L’aspergillosethoracique:indicationschirurgicalespourune affectionàfacettesmultiples!RevPneumolClin2004;60(2):73–7.
[24]GodetC,LaudaM,RoblotF.Aspergillosechroniquecavitairecompliquant uneBPCO.RevMalRespir2013;5:31–4.
[25]Germaud P, Renaudin K, Danner I, Morin O, De Lajartre AY. Les aspergillosesbroncho-pulmonaires:lesnouveauxenjeux.RevMalRespir 2001;18(3):257–66.
[26]GazzoniFF,SeveroLC,MarchioriE,GuimaraesMD,GarciaTS,IrionKL, etal.PulmonaryDiseaseswithImagingFindingsMimickingAspergilloma.
Lung2014;192(3):347–57.
[27]MimouniI,Lezar S,EssodeguiF,Zamiati W,Adil A.L’aspergillome intracavitaire pulmonaire: à propos de 24 cas. J Radiol 2009;90:
1591.
[28]FajraouiN,BejiM,LouzirB,MehiriN,CherifJ,HajjiS,etal.Aspergillome pseudo-tumoral.RevPneumolClin2001;57(6):431–3.
[29]CouturaudF.Aspergillusetpoumon.RevFrAllergol2004;44:83–8.
[30]StankovicK,SèveP,HotA,MagyN,DurieuI,BroussolleC.Aspergilloses aucoursdemaladiessystémiquestraitéesparcorticoïdeset/ouimmuno- suppresseurs:analysedeneufcasetrevuedelalittérature.RevMedInterne 2006;27:813–27.
[31]GironJ,SansN,PoeyC,FajadetP,FourcadeD,SenacJP,etal.Traite- mentpercutanéradiologiquedesaspergillomespulmonairesinopérables: àproposde42cas.JRadiol1998;79(2):139–45.
[32]YuanP,WangZ,BaoF,YangY,HuJ.Isvideo-assistedthoracicsurgerya versatiletreatmentforbothsimpleandcomplexpulmonaryaspergilloma?
JThoracDis2014;6(2):86–90.
[33]MassardG.Placedelachirurgiedansletraitementdesaspergillosestho- raciques.RevMalRespir2005;22(3):466–72.
[34]MuniappanA,TapiasLF,ButalaP,WainJC,WrightCD,DonahueDM, etal.Surgicaltherapyofpulmonaryaspergillomas:a30-yearnorthamer- icanexperience.AnnThoracSurg2014;97(2):432–8.
[35]AkbariJG,VarmaPK,NeemaPK,MenonMU,NeelakandhanKS.Clinical profileandsurgicaloutcomeforpulmonaryaspergilloma:asinglecenter experience.AnnThoracSurg2005;80(3):1067–72.
[36]KilaniT,BoudayaMS,ZribiH,OuerghiS,MarghliA,MestiriT,etal.
Lachirurgiedanslatuberculose thoracique. RevPneumolClin2014, http://dx.doi.org/10.1016/j.pneumo.2014.03.005.
[37]FeltonTW,BaxterC,MooreCB,RobertsSA,HopeWW,DenningDW.
Efficacyandsafetyofposaconazoleforchronicpulmonaryaspergillosis.
ClinInfectDis2010;51(12):1383–91.