Intracavitary voriconazole for the treatment of hemoptysis complicating Pseudallescheria angusta pulmonary mycetomas in fibrocystic sarcoidosis.

Pulmonary mycetomas often occur in fibrocystic sarcoidosis. When this condition is complicated by hemoptysis, definitive surgery is usually precluded because of poor lung function. Intracavitary antifungal therapy has been described for the treatment of symptomatic pulmonary mycetomas. We report the first use of intracavitary voriconazole in the management of a Pseudallescheria angusta pulmonary mycetoma complicated by hemoptysis in a patient with fibrocystic sarcoidosis and renal transplant.

A modern series of percutaneous intracavitary instillation of amphotericin B for the treatment of severe hemoptysis from pulmonary aspergilloma.

BACKGROUND: Pulmonary aspergillomas may cause life-threatening hemoptysis. The treatment of this condition is problematic because poor pulmonary function often precludes definitive surgical resection. METHODS: We retrospectively reviewed all patients hospitalized at our institution for hemoptysis associated with an aspergilloma over an 8-year period and who underwent percutaneous intracavitary instillation of amphotericin B (ICAB). ICAB consisted of catheter placement into the aspergilloma cavity with subsequent instillation of 50 mg amphotericin B in 20 mL 5% dextrose solution daily for 10 days. RESULTS: ICAB was attempted for 23 distinct episodes of severe hemoptysis in 20 individual patients. Catheter placement was successful in 21 of the 23 episodes (91%), and of these, ICAB instillation was successfully completed in 20 episodes (95%). In these 20 episodes, hemoptysis ceased by hospital discharge in 17 of 20 patients (85%) and in all 18 who survived until a follow-up visit 1-month after treatment. Pneumothorax occurred in six of 23 (26%) catheter placement attempts without long-term complications. Recurrence of serious hemoptysis occurred after six of 18 episodes for which follow-up was available. Potential risk factors associated with severe, recurrent hemoptysis were a size increase or reappearance of the aspergilloma on a chest CT scan (P = .001), bleeding diathesis (P = .08), and lack of bronchial artery embolization during index hospitalization (P = .07). CONCLUSIONS: Our data suggest that ICAB is an effective short-term treatment to control severe hemoptysis caused by pulmonary aspergilloma. The long-term benefit of this procedure is unknown. We identified several potential risk factors for recurrent hemoptysis after ICAB that could be examined prospectively in future trials.

How should we treat vascular and fibrotic lung disease in scleroderma?

Recent randomized trials suggest that evidence-based algorithms for systemic sclerosis can be developed to identify patients at risk for lung disease, follow lung disease progression, and modify disease with therapies of proven benefit. Recognition of disease subsets allows physicians to integrate physiology, overlapping disease manifestations, and predictable drug effects into a comprehensive disease management program.