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Short Reports Mixed Allergic Bronchopulmonary Fungal Disease Thorax 1990;45:489-492 489 Short reports Thorax: first published as 10.1136/thx.45.6.489 on 1 June 1990. Downloaded from Mixed allergic bronchopulmonary I' fungal disease due to Pseudallescheria boydii and Aspergillus Fiona R Lake, Anthony E Tribe, Rose McAleer, Joseph Froudist, Philip J Thompson - - - Abstract Figure 1 Chest radiograph at admission. A 24 year old asthmatic woman with mixed allergic bronchopulmonary fungal disease due to Pseudallescheria boydii her only medication was inhaled salbutamol and Aspergillus is reported. No previous and the oral contraceptive pill. cases due to P boydii have been described. On admission she had a cough producing This patient provides evidence that fungi green-brown sputum with obvious plugs. Her other than Aspergillus species may cause asthma appeared stable, she was afebrile, and the condition. she had bronchial breathing over the right upper zone. Chest radiographs four months earlier showed a left upper lobe infiltrate http://thorax.bmj.com/ Allergic bronchopulmonary fungal disease extending from the hilum. Subsequent radio- is characterised by asthma, eosinophilia, graphs showed changing recurrent shadows infiltrates on the chest radiograph, raised IgE and when she was admitted there was con- levels, precipitating antibodies, and immediate siderable right hilar shadowing (fig 1). The skin reactivity to the causal fungus.' Its forced expiratory volume in one second (FEV,) management differs from that of simple asthma and forced vital capacity (FVC) were 2-2 and and frequently requires prolonged use of 2 9 litres, (predicted 3 0 and 3-6 1). A full blood corticosteroids to minimise development of count showed eosinophilia (1-7 x 109 cells/l; on September 25, 2021 by guest. Protected copyright. proximal bronchiectasis. normal < 0-4 x 109) and the total IgE was Aspergillus species are the most common greater than 4000 IU (normal < 300 IU). Skin fungi implicated in allergic bronchopulmonary prick testing was performed with reagents from fungal disease, but more recently other fungi, the Hollister Stier Laboratories, Washington. including Curvularia, Drechslera,2 Helmintho- In addition a freeze dried cytoplasmic extract sporium, Candida albicans, Stemphylium, of P boydii was prepared by the method Torulopsis, and Bipolaris' have been reported. described by Mackenzie et al5 and recon- Sir Charles Gairdner Hospital, Perth Mixed fungal infection has been recognised stituted to 20 mg of freeze dried extract/ml of F R Lake less frequently.2 distilled water for skin prick testing. The A E Tribe Pseudallescheria boydii is a common soil patient had skin weal responses as follows: Medical Mycology fungus that is increasingly reported as a human Aspergillusfumigatus (6 mm), A terreus (7 mm), Laboratory, State pathogen,4 but has not previously been Health Laboratories, A niger (3 mm), A nidulans (3 mm), Alternaria Perth implicated in allergic bronchopulmonary sp (8 mm), Helminthosporium (9 mm), Curvu- R McAleer fungal disease. We report a case due to P boydii laria sp (12 mm), Stemphylium botryosum (10 J Froudist and Aspergillus in an asthmatic patient. mm), and P boydii (7 mm). The skin reaction to Department of 1 0 mg/ml of histamine was 6 mm. Precipitat- Medicine, University of Western Australia, ing antibodies were detected by the double Perth, Australia immunodiffusion technique5 with cytoplasmic P J Thompson Case report extracts of the fungi, the patient's serum, and a Address for reprint requests: A 24 year old atopic woman with asthma was control solution of hyperimmune rabbit anti- Dr P J Thompson, University Department of admitted to hospital with a four month history serum. Antibodies were detected in the Medicine, Queen Elizabeth of two prolonged episodes of cough producing patient's serum on two occasions one month II Medical Centre, Nedlands, Western Australia purulent sputum. Broad spectrum antibiotics apart. Initial assessment showed the presence 6009, Australia. were unhelpful. The patient had lived in non- of P boydii (two bands), A fumigatus (three Accepted 19 December 1989 tropical rural areas of Western Australia and bands), and A flavus (one band) and on the 490 Lake, Tribe, McAleer, Froudist, Thompson Figure 2 Typical conidia borne singly at the tips of conidiophores. Thorax: first published as 10.1136/thx.45.6.489 on 1 June 1990. Downloaded from A4 'A * second occasion P boydii (three bands), vegetation, poultry and cattle manure, and A flavus (one band), and A terreus (one band). water.4 In addition to causing maduromycosis Aspergillus species did not cross react with (madura foot) it has increasingly been reported P boydii in immunodiffusion studies using as a pathogen at other sites4 and in disseminated http://thorax.bmj.com/ hyperimmune rabbit antisera. infection.6 At bronchoscopy plugs of sputum were Disease due to P boydii has been infrequently aspirated from the right upper lobe. A reported and this may reflect problems with its bronchoalveolar lavage specimen showed a identification. P boydii resembles other fungal high neutrophil (760/1) and eosinophil count species in tissue specimens and may be difficult (12.50,o) (normal: neutrophils < 2%, eosino- to distinguish from Aspergillus species. phils < 0-5°h). Four bronchoscopy specimens Cultures definitely identifying the fungus are and one sputum specimen were cultured at thus required for a diagnosis. Serological on September 25, 2021 by guest. Protected copyright. 25°C and 37°C on five media. All specimens antibody testing and skinprick testing may also showed large amounts of septate branching be helpful, particularly if allergic disease is mycelia and grew multiple colonies ofP boydii, suspected. which were floccose, smoky grey on the The lung is the most common extra- surface, and blackish on the reverse. The cutaneous site of infection, 31 cases of fungus grew initially in the anamorph state, pulmonary infection having been reported.4 7-10 Scedosporium apiospermum (fig 2), but was later Manifestations of infection have included induced to produce ascomas on water agar. asymptomatic coin lesions, lung mycetoma, Occasional colonies of A terreus were also necrotising pneumonia with associated grown. bronchiectasis or abscess formation, transient The patient was treated with prednisolone 40 colonisation, and an infected pleural effusion mg per day for six weeks, which was decreased (one report). Of these, mycetoma was the most over a further four weeks and then stopped. common. Of the patients reported, only five Salbutamol was continued and theophylline neither had underlying lung disease nor were added. The symptoms improved rapidly and immunosuppressed.4"'0 No cases of allergic four weeks later a chest radiograph showed bronchopulmonary fungal disease due to almost complete clearance of the infiltrates. P boydii have been reported. Results of ventilatory capacity tests also Aspergillus species were the initial fungi improved (FEVy and FVC being 2-8 and 3-5 1). to be recognised as causing allergic broncho- pulmonary fungal disease when the condition was first described in 1952 and remain the most Discussion common fungi implicated in the disease. Mixed Pseudallescheria boydii belongs to the class allergic bronchopulmonary fungal disease has Ascomycetes. It has a worldwide distribution, been described2 but seems uncommon. Our particularly in soil, where it is a natural sapro- patient had six major and two minor criteria for phyte. It has also been isolated from decaying the diagnosis of allergic bronchopulmonary Mixed allergic bronchopulmonaryfungal disease due to Pseudallescheria boydii and Aspergillus 491 fungal disease, on the basis of Greenberger's associated with Aspergillus species. In criteria for allergic bronchopulmonary asper- suspected allergic bronchopulmonary fungal gillosis.' The strongly positive precipitin bands disease where all tests for Aspergillus give and skin test responses to P boydii and the negative results the possibility of other fungi, heavy growth of the fungus confirm its likely such as P boydii, as causative agents should be Thorax: first published as 10.1136/thx.45.6.489 on 1 June 1990. Downloaded from pathogenicity in this patient. Additionally, the investigated. growth of Aspergillus terreus, with a positive skin test response and precipitins, is consistent 1 Greenberger PA. Allergic bronchopulmonary aspergillosis. with mixed allergic bronchopulmonary J Allergy Clin Immunol 1984;74;645-52. fungal 2 McAleer R, Kroenert DB, Elder JL, Froudist JH. Allergic disease. bronchopulmonary fungal disease caused by Curvularia lunata and Drechslera hawaiiensis. Thorax 1981;36: Our patient also had positive skin test 338-44. reactions and precipitins in response to other 3 Adam RD, Paquin ML, Petersen EA, et al. Phaeo- fungi, a finding common in asthmatic hyphomycosis caused by the fungal genera Bipolaris and patients, Exserohilum. A report of 9 cases and a review of the individuals who do not have allergic broncho- literature. Medicine (Baltimore) 1986;65:203-17. pulmonary fungal disease. The clinical signi- 4 Rippon JW, Carmichael JW. Petriellidiosis (allescheriosis): four unusual cases and review of literature. Mycopatho- ficance of these reactions is not clear and their logia 1976;58:117-24. presence may in part be due to cross 5 MacKenzie DWA, Proctor AGJ, Philpot CM. Basic reactivity serodiagnostic methods for disease caused by fungi and between common fungi. Cross reactivity be- actinomycetes. London: Public Health Laboratory tween Aspergillus species exists, though in this Services,
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