Pulmonary infections by the fungus aspergillusPV Rao, PG Shivananda, S Vikineshwari, G Vasavi, KNA Rao
Departments of Microbiology and Medicine, Kasturba. Medical College, Manipal 576 119, Karnataka, India
Five cases of respiratory infection by Aspergillus fumigates are described. Species of aspergillus is ubiquitous in nature. Therefore, repeated demonstration of fungus, serological evidence tend radiological findings are essential for diagnosis. Potassium iodide is a useful drug in aspergillus infection of the lung when other drugs are not available. Injection Emetine hydrochloride is promising as a therapeutic agent in pulmonary aspergillosis, where the lung parenchyma is involved.
Recently, Aspergillus as a secondary invader is being recognised with increasing frequency. Out of about :350,species , described, only a few are considered as pathogenic to man notably Aspergillus fumigatus. 
We describe below four cases of pulmonary aspergillosis and one case of pulmonary aspergilloma diagnosed in the Kasturba Medical College Hospital, Manipal, during June 1974 to June 1977.
Cases clinically and radiologically diagnosed as pulmonary tuberculosis, but had failed to respond to antitubercular treatment were re-examined or reviewed. In five such cases fungal elements could be demonstrated and cultured. Sputum specimens were collected with strict asceptic precautions as far as possible.
Soon after waking, the patient was asked to rinse his mouth thrice with sterile saline and all the coughed up expectorate was collected directly into a sterile wide mouthed container. This was repeated on three consequtive days. Bronchial aspiration materials were collected in a sterile container.
The sputum and bronchial aspiration materials were processed soon after the collection. The sputum was transferred to a sterile petri-dish. Purulent portion of sputum was selected for wet smear preparation with 20% KOH.  Smears were also made and stained by Gram's and Ziehl Neelsen's methods. The material was cultured on Blood agar, Lowenstein Jensen, Robertson's Cooked Meat Medium and Sabourauds Glucose Agar in duplicate. (One tube was incubated at 37°C and the other at 25'C). Sputum was also examined for the presence of malignant cells.
The patients' sera were put up for gel precipitation tests by Ouchterlony technique and the antigen for gel diffusion was prepared according to the method described by Longbottom et al  except that the final concentrated dialysate was not lyophilised.
Case 1: A 32 year old male farmer suffered from cough with expectoration for the last six months and did not give any history of haemoptysis. His hemoglobin was 12 grams% . The systemic examination revealed only crepitations which were heard over both the lung fields. Blood examination showed eosinophil count of 17% and ESR was 12 mm 1st hour (Westergren). The radiograph showed diffuse mottling in both the lung fields (See [Figure 1] on page 56B). This patient expired after 6 months. Conant's rapid regimen of Potassium iodide treatment did not help him.
Case 2: A 41 year old male patient sought our advice for the complaints of haemoptysis and cough of last two months' duration. The patient was anaemic (Hemoglobin 10 grams) and clubbing of the fingers were present. He said he had suffered from pulmonary tuberculosis about 10 years back. The systemic examination did not reveal anything except that coarse crepitations were heard over the left supra and intrascapular regions. The blood examination showed eosinophil count of 29% and ESR was 10 mm 1st hour (Westergren). The X-ray picture showed a large cavity in the left upper lobe completely filled with a "fungal ball" separated by a clear margin. No fluid level was observed, (See [Figure 2] on page 56B). This patient reponded well to our saturated solution of potassium iodide (See [Figure 3] on page 56B).
Case 3: A 35 year old farmer suffering from infective hepatitis for the last 15 days was admitted for this complaint. He also gave a history of suffering from cough with expectoration for the last six months. The systemic examination did not reveal any abnormalities. His eosinophil count was 16% and ESR was 12 mm 1st hour (Westergren). The radiograph showed a homogenous opacity in the right mid zone. As this lesion was diffuse and not demarkated, it was considered to be a diffuse or paranchymatous type. Histopathological evidence confirmed that the hepatitis was of viral etiology. He also responded well to Conant's regimen.
Case 4: A 40 year old house-wife came with complaints of cough with expectoration and breathlessness of 4 months' duration. Associated with this she had pain in the chest and haemoptysis for the last 2 months. The sputum was whitish and non-foul smelling, Systemic examination did not give any positive findings. The blood examination showed eosinophils of 20% and ESR 16 mm 1st hour (Westergren). The chest radiograph showed homogenous opacity in the right mid zone, a lesion similar to the one described above. This patient also responded well to the potassium iodide treatment.
Case 5: A 28 year old male was admitted to the hospital for the complaints of cough with expectoration and haemoptysis of 6 months' duration. The chest X-ray showed diffuse mottling in both the lung fields and was originally suspected to be a case of miliary tuberculosis. The blood examination showed 21% eosinophils and ESR was 10mm 1st hour (Westergren). This patient was treated with injection Emetine hydrochloride 60 mg per day for a period of 10 days  and the response has been very promising and dramatic.
In all our cases, wet mount preparation and direct smear were positive for hyphal fragments and characteristic fungal spores were seen in many. All sputum samples were negative for acid fast bacilli by direct smear, by concentration method (Petroff's) and by culture. They were negative for malignant cells. No anaerobic organisms were isolated in Robertson's Cooked Meat Medium and Thioglycollate medium. In all the patients, Aspergillus fumigatus was isolated and identified according to Conant et al.  Sera from all five patients gave precipitation lines with Aspergillus fumi gatus antigen only.
The other organisms grown were Staphylococcus coagulase negative in 3 cases and Beta-haemolytic streptococci in the other two. These were grown on blood agar plate alongwith Aspergillus.
The spores of the Aspergillus species are widely distributed in nature and are frequently found in the soil and the vegetable matter. Aspergillus fumigatus and Aspergillus niger are able to grow in or in close association with human tissue, the respiratory tract being the most frequent point of contact.  In the review article by the British Tuberculosis Association, a review of 544 cases of healed pulmonary tuberculosis with residual cavities showed 171; aspergilloma and 3% probable aspergilloma in about 3-4 years of follow up.  However only one case cited by us gave a definite history of pulmonary tuberculosis.
It is well documented that the saprophytic fungus may be changed into an opportunistic pathogenic form by the indiscriminate use of antibiotics and immunosuppressive agents.  In all our cases they had received several antibiotics and corticosteroids at the local hospital.
The Aspergillus infections of the lung are regarded by many as an occupational hazard particularly with those agriculturists who are working with hay, grain and flour. ,, In our cases, four of them were farmers. Experimentally animals have been infected following the inhalation of spores with subsequent germination and proliferation in the lung tissues. 
Aspergillosis is a most troublesome laboratory contaminant. Being ubiquitous, one has to be very careful to incriminate this fungus as an aetiological agent. However, we are of the opinion that the presence of Aspergillus in the clinical material perticularly sputum, should not be ignored as a contaminant and the case must be investigated in full detail. The diagnosis of pulmonary aspergillosis and aspergilloma depends up-on the clinical symptoms, radiological findings and the repeated demonstration and isolation of the fungus in the sputum.  The growth of the fungus from the bronchial aspiration material  and demonstration of precipitin in the patient's serum are of value in the diagnosis of Aspergillus infection  and could be the conclusive evidence. 
Therapy still remains a problem. Iodides, nystatin and amphotericin-B, have been tried with uncertain results.  For want of sophisticated drugs we resorted to Conant's regimen.  Three cases improved both radiologically and clinically and the sputum examination did not reveal any fungus after treatment. These patients are being followed up. One patient who was a well advanced case did not respond to potassium iodide treatment and died after 6 months. No postmortem was allowed by the relatives.
Injection Emetine hydrochloride has been tried in pulmonary aspergillosis and the reports were favourable.  We also tried this in one case of pulmonary aspergillosis and the response to this treatment has been promising. The haemoptysis which was continuous and a major feature had subsided and the patient's general condition was consider ably improved both clinically and radio logically
[Figure 1], [Figure 2], [Figure 3]