Topical Amphotericin B Applicationin Severe Bronchial Aspergillosisafter Lung Transplantation: Reportof Experiences in 3 CasesHeidi Boettcher, MD,ab Burkhard Bewig, MD,b Stephan W. Hirt, MD,a

Frank Moller, MD,a and Jochen Cremer, MDa

Ulcerative tracheobronchial aspergillosis after lung transplantation (ltx) may lead tobronchial–pulmonary artery fistula that results in fatal bleeding. We report our earlyexperience with combined systemic, aerolized and topical application of amphotericin Bin 3 cases of bronchial aspergillosis after ltx. Two patients are still alive, but 1 died ofbleeding from a fistula between the left upper lobe bronchus and the pulmonary artery.Aspergillosis in the second patient resolved with minimal stenosis of the left main andthe left upper lobe bronchus, and the third patient developed an anastomotic stenosisthat was successfully dilated. J Heart Lung Transplant 2000;19:1224–1227.

Invasive aspergillosis is a life-threatening com-plication in patients with immunosuppression,especially after lung transplantation (ltx). In 1991,Kramer et al1 reported 2 deaths caused by bron-chial aspergillosis that spread to the lung paren-chyma. Because of the histopathologic aspectof the bronchi, they termed it ulcerativetracheobronchitis. Since then, further cases offatal bleeding after development of bronchialaspergillosis–associated fistula between a bron-chus and the pulmonary artery or aorta have beenreported.2–5

CASE REPORTS

We report the course and outcome of 3 patientswith invasive bronchial aspergillosis who receivedcombined anti-fungal treatment with systemic,aerolized, and topical amphotericin B, applied

bronchoscopically. We detected Aspergillus infec-tion in all cases 2 to 4 weeks after ltx, at a time ofhighest immunosuppression. All patients receivedanti-thymocyte globulin. Maintenance therapyconsisted of cyclosporin A (through level 250 to300 ng/ml; Abbott monoclonal antibody fluores-cence polarization immunoassay), azathioprine (2mg/kg), and prednisolone (initially 0.5 mg/kg,reduced over 3 months to 0.1 mg/kg). Treatmentfor acute rejection was 0.5 to 1.0 g/day methyl-prednisolone over 3 days in each instance. Post-operatively, patients received routine anti-fungalprophylaxis with 200 mg fluconazole daily until alllines were withdrawn. Long-term oral prophylaxiswith itraconazole 200 mg per day was introducedat our center after Patient 1 of this report died.Therefore, the other 2 patients received anti-fungal prophylaxis with itraconazole when As-pergillus species was detected for the first time.All 3 patients received bilateral lung transplanta-tion using end-to-end single-stitch technique forthe bronchial anastomoses, without tissue wrap-ping and without revascularization of the bron-chial arteries. The donor lungs were harvestedafter excellent low-pressure perfusion with 4,000ml cold Euro-Collins solution enriched with pros-tacycline. Cold ischemia time ranged from 217 to240 minutes for the right lungs and from 326 to346 minutes for the left lungs.

From the aDepartment of Cardiovascular Surgery, Kiel Univer-sity Hospital, Kiel, Germany; and bDepartment of InternalMedicine, Kiel University Hospital, Kiel, Germany.

Submitted February 23, 2000; accepted June 5, 2000.Reprint requests: Heidi Boettcher, MD, Department of Cardio-

vascular Surgery, Kiel University Hospital, Arnold-Heller-StraBe 7, 24105 Kiel, Germany. Telephone: 49-431-597 4400.Fax: 49-431-597 4402. E-mail: hboettcher@kielheart.uni-kiel.de.

Copyright © 2000 by the International Society for Heart andLung Transplantation.

1053-2498/00/$–see front matter PII S1053-2498(00)00154-6

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Case 1

A 42-year-old female received ltx in May 1996because of lymphangioleiomyomatosis. Necropsy ofthe explanted lungs showed unexpected Aspergillusspecies within necrotic bronchi and the surroundingtissue. At bronchoscopy 14 days after ltx, bothanastomoses and the main bronchi were coveredwith purulent secretions containing Aspergillus fu-migatus on microscopy and culture. Further necroticplaques were present more distally at both sides.Therapy with itraconazole (200 mg per day) was

started. After steroid pulse treatment for an acuterejection episode 5 weeks after ltx, ongoing bron-chial aspergillosis developed, which led to occlusionof the left main bronchus 8 weeks after ltx. Thera-peutic debridement and combined anti-fungal treat-ment consisting of liposomal amphotericin B(lAmB; 150 mg/d) and flucytosine (2.5 mg threetimes a day) intravenously (IV) as well as aerolizedconventional amphotericin B (cAmB; 2 310 mg)was started. However, the disease progressed, andwhen minor bleeding (9 weeks after ltx) at the leftupper lobe occurred after a rigid bronchoscopy,which was necessary for debridement, topical cAmBwas applied as ultima ratio therapy. We applied 50

FIGURE 1 Fistula, indicated by the sonde, between theleft upper lobe bronchus (LUL) and the pulmonaryartery (PA). The left main bronchus (LMB), with anunremarkable anastomosis (arrow), and the left lowerlobe bronchus (LLL) are also depicted.

FIGURE 2 Histologic section through a destroyedbronchial cartilage showing aspergillus hyphae (arrows)inside the cartilage and the surrounding tissue.

FIGURE 3 Endoscopic view on the left anastomosis of case 3. On the left (A) theanastomosis is covered with purulent secretions containing Aspergillus species at day 57after lung transplantation. In the middle (B), 94 days after ltx, aspergillus and secretionswere completely cleared but severe stenosis had emerged. On the right (C), theanastomosis after repeated dilation 246 days after ltx with a residual stenosis, which couldeasily be passed during bronchoscopy.

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mg cAmB (5 mg/ml aqueous solution) on both sides.The next day, bronchoscopy showed marked soften-ing of the secretions, which made debridement withflexible bronchoscopy easier. Again 30 mg cAmBwere dispensed, preferentially on the left side. Bron-choscopy the following day revealed a soft purulentstrand occluding the left main bronchus duringinspiration but floating with the air stream duringexpiration. During careful extraction this strand wassustained, followed by a thin tissue layer leading tointractable, fatal bleeding. Autopsy revealed a fis-tula between the left upper lobe bronchus and thepulmonary artery (Figure 1). Aspergillus was foundin the surrounding tissue, but not in the lung paren-chyma.

Case 2

In December 1996, a 36-year-old female received ltxbecause of a1-antitrypsin deficiency. One and 2weeks after ltx, steroid pulse therapy was necessaryto treat 2 acute rejection episodes. After 4 weeks,bronchoscopy showed necrosis of both main bron-chi, and we cultured Aspergillus flavus from bron-choalveolar lavage. We began treatment usinglAmB (150 mg) and flucytosine (2.5 g twice a day)IV and aerolized lAmB (50 mg three times a day).Two weeks later, purulent secretion, which was fullof Aspergillus, covered and nearly obstructed theleft upper lobe bronchus. Local application usingboth cAmB and lAmB 2 to 3 mg (0.5 mg/ml aqueoussolution) was started bronchoscopically 2 to 3 timesa week for a total of 4 weeks, resulting in clearanceof the purulent secretions. However, microscopicexamination of an endobronchial biopsy showedfurther Aspergillus species inside the bronchial car-tilage (Figure 2). Because of intractable nausea andvomiting as well as progressive tracheitis, westopped topical treatment, but proceeded with sys-temic and aerolized treatment for additional an 2(IV) and 6 (aerolization) weeks, respectively. Wediscovered that the nausea and vomiting resultedfrom adrenal insufficiency, which was exacerbatedby cytomegalovirus infection. Because of anti-fungaltreatment, this patient also suffered a decrease inrenal function. Only a minimal stenosis of the leftmain and upper lobe bronchus developed. Both canbe easily passed during bronchoscopy. The patientremains well, although histologically proven bron-chiolitis obliterans occurred 2 years after ltx.

Case 3

In February 1998, a 46-year-old male developednecrosis near the left anastomotic suture 2 weeks

after bilateral ltx for a1-antitrypsin deficiency. Fiveweeks later, we cultured Aspergillus fumigatus frombronchoalveolar lavage, and the patient began re-ceiving IV flucytosine 2.5mg (four times a day) andlAmB (200 mg) as well as aerolized treatment withlAmB (50 mg three times a day). One week later,the patient was admitted because of pneumothoraxon the left side. Endoscopy showed the anastomosiswas covered with purulent secretion (Figure 3A).The absence of tryptophan-blue in the drainagefluid after bronchoscopically directed applicationruled out severe dehiscence. Because of massiveAspergillus in the secretion, topical treatment wasstarted. The patient received 2 to 3 mg lAmB (0.5mg/ml aqueous solution) bronchoscopically on hisleft anastomosis once a week for a total of 4 weeks,resulting in a progressive reduction of secretions ateach control bronchoscopy. However, circular tissueproliferation followed the loss of secretion, with thedevelopment of a stenosis 97 days after ltx (Figure3B), which was successfully dilated in several inter-ventions within 4 to 8 months after ltx. The patientremains well at BOS 0 with an unchanged clinicallyinsignificant residual stenosis of the left bronchialanastomosis (Figure 3C).

DISCUSSION

In this series, 3 patients with bronchial aspergillosisreceived combined anti-fungal treatment consistingof systemic, aerolized, and local application of am-photericin B. In all cases, topical application wasadded to systemic and aerolized treatment whenprogressive extensive secretion containing Aspergil-lus was noted.

Hemoptysis, hemoptoe, and bleeding are knowncomplications of invasive pulmonary aspergillosis,but commonly patients die of respiratory failure. In1991, Kramer et al1 described 2 deaths after bron-chial aspergillosis had spread secondarily into thelung parenchyma. Yeldandi et al6 described success-ful systemic treatment of bronchial aspergillosisusing AmB and/or itraconazole, whereas Kessler etal5 reported treatment failure of oral itraconazoleand oral voriconazole resulting in fatal bleeding 3months after ltx. Birsan et al4 described 3 cases withsuccessful anti-fungal treatment of bronchial as-pergillosis using aerolized AmB and oral itracon-azole. However, all aspergilloses occurred unusuallylate, at 3, 6, and 8 months after ltx, when initialimmunosuppressive therapy, especially with ste-roids, is usually reduced. Unfortunately, this reportgives no information about immunosuppression. Inour cases, the first detection of aspergillosis oc-

1226 Boettcher et al. The Journal of Heart and Lung TransplantationDecember 2000

curred between 2 and 4 weeks after ltx, and weidentified Aspergillus species on necrotic areas ofthe donor bronchus near the anastomotic site. Atthis time, immunosuppression was still at the upper-most level and superinfection may have caused thedevelopment of wall adherent, purulent secretions,and tissue invasion. Because of encasing by necrosisand secretions, Aspergillus may escape systemic andaerolized treatment.

Topical or local treatment with AmB is a well-established treatment for prevention and therapy ofcandida mucositis and esophagitis, having few sideeffects in the absence of systemic absorption. Rec-ommended doses are 50 mg to 600 mg, given in 4 to6 parts as tablets or suspension. Effectiveness oftopical AmB is also established in the treatment ofocular mycosis (20 to 100 mg, given between every 30minutes and three times daily), but can injure epi-thelium followed by stromal shade and iridocyclitis.For other organs, local application is recommendedin dosages of 0.1 mg to 0.5 mg intralumbar formeningitis, 2 mg for pleuritis or pericarditis, and 5 to20 mg every 48 hours intra-articular for arthritis. Asdrainage it is applied with 50 mg for cystitis or1mg/liter for peritonitis8. In aspergilloma, local in-stillation using 5 to 50 mg9 daily led to the develop-ment of empyema. However, in empyema it wasused with 20 mg twice a day, but improvementoccurred only when aerolized liposomal amphoter-icin B was added.10

To our knowledge, no reports exist of topicalendobronchial AmB application in humans or ani-mals. In Case 1 of this report, we used topicalapplication as ultima ratio therapy, when a bleedingcomplication had already occurred. We started with50 mg to 30 mg at each performance. Remarkablesoftening of the secretions suggested successful anti-fungal treatment, but the development of a fistulaled to fatal bleeding. Because of this singular trial itwas not possible to differentiate the cause of fistuladevelopment between successful but delayed anti-fungal treatment or local tissue toxic effects. There-fore we decreased doses to 2 to 5 mg in Cases 2 and3, which was successful in eradicating fungal infec-tion. However, the second patient showed manifesttracheitis due to frequent bronchoscopies and thethird case developed severe anastomotic stenosis.

Reports on anti-fungal prophylaxis after ltx11,12

mainly concern the avoidance of parenchymal ordisseminated invasive aspergillosis. To our knowl-

edge, no proven protocols exist for prophylaxis offungal superinfection or healing deficiencies, andtherefore severe complications bearing the risk for afatal outcome may occur after ltx.

In conclusion, we think that the topical applica-tion of conventional or liposomal amphotericin B isa promising additional therapeutic option in thetreatment of bronchial aspergillosis. However, doseadjustment and frequency of bronchoscopic inter-ventions need to be investigated.

We gratefully acknowledge the contributions of J.Oschliesand O. Frahm, Department of Pathology, who provided uswith Figures 1 and 2. We also thank M. Ernst for hisassistance in preparing this manuscript.

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2. Hoff SJ, Johnson JE, Frist WH. Aortobronchial fistula afterunilateral lung transplantation. Ann Thorac Surg 1993;56:1402–3.

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4. Birsan T, Taghavi S, Klepetko W. Treatment of aspergillus-related ulcerative tracheobronchitis in lung transplant recip-ients. J Heart Lung Transplant 1998;17:437–8.

5. Kessler R, Massard G, Warter A, Wihlm JM, WeitzenblumE. Bronchial-pulmonary artery fistula after unilateral lungtransplantation: a case report. J Heart Lung Transplant1997;16:674–7.

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9. Ryan PJ, Stableforth DE, Reynolds J, Muhdi KM. Treatmentof pulmonary aspergilloma in cystic fibrosis by percutaneousinstillation of amphotericin B via indwelling catheter. Thorax1995;50:809–10.

10. Purcell IF, Corris PA. Use of nebulised liposomal amphoter-icin B in the treatment of Aspergillus fumigatus empyema.Thorax 1995;50:1321–3.

11. Palmer SM, Whitehouse JD, McConnell RR, et al. Nebulizedamphotericin B lipid complex prophylaxis is associated with alow rate of invasive fungal infection after lung transplanta-tion. Am J Respir Crit Care Med 1998;157:A330.

12. Reichenspurner H, Gamberg P, Nitschke M, et al. Significantreduction in the number of fungal infections after lung-,heart-lung, and heart transplantation using aerolized ampho-tericin B. Transplant Proc 1997;29:627–62.

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