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Severe Hemoptysis Associated with

Pulmonary Aspergilloma
Percutaneous Intracavitary Treatment
Marcellej Shapiro, M.D.;* Steven M. Albelda, M.D.;t
Robert L. Mayock, M.D., F.C.C.P;t and Gordon K. McLean, M.D.*

Surgical therapy for massive hemoptysis associated with N-acetylcysteine, and aminocaproic acid. Advantages of
pulmonary aspergilloma carries a high morbidity and this method of treatment for patients with severely corn-
mortality in patients with limited pulmonary reserve. promised pulmonary reserve include: (1) no further loss of
Bronchial artery embolization has proven ineffective in lung function; (2) ease and rapidity of catheter insertion;
treating and in preventing recurrent episodes of hemoptysis (3) prompt response to treatment; (4) relatively short
in this group of patients. Over a four-and-one-half year hospitalization; and (5) ability to repeat the procedure in
period, we have successfully treated six episodes of acute the same or another cavity if necessary. (Chest 1988;
hemoptysis in four patients using a percutaneously placed 94:1225-31)
catheter and intracavitary instillation of amphotericin B,

M assive hemoptysis is the cause ofdeath in 2 to 26 to the bronchial art Any embolization of this
percent of patients with pulmonary aspergil- complex and extensive systemic arterial network re-
loma. Fatal hemorrhage from aspergilloma is the quires a high degree ofskill and complete embolization
second most common cause of death in sarcoidosis.2 may be impossible. 13
Traditionally, surgical resection of the involved pul- Antifungal agents have been used in a variety of
monary tissue has been advocated as the treatment of ways. Intravenous amphotericin B has been shown to
choice, although morbidity and mortality rates may be no more effective than routine pulmonary 15
run as high as 25 percent and 8 percent, respec- Several investigators have instilled antifungal agents
112 The foregoing statistics apply to those patients endobronchially67 or via a transthoracic route into
with adequate pulmonary reserve and unilateral hem- the cavity82 in symptomatic, but relatively stable
orrhage. Surgery is even more hazardous for the many patients with aspergilloma. Only one of these studies,
patients with massive hemoptysis and pulmonary a case report,2 has examined the usefulness of this
aspergilloma who have severe underlying pulmonary technique during an acute episode of hemoptysis.
disease. The extremely high morbidity and mortality Over the past four and one half years, we have
of surgery in this subgroup of patients has prompted successfully treated six episodes of severe hemoptysis,
a search for other forms of therapy. including three episodes of massive hemoptysis (>600
Bronchial artery embolization has proven successful ml/24 hours), in four patients with pulmonary asper-
in controlling massive hemoptysis occurring with tu- gillomas and severe underlying lung disease using a
berculosis, bronchiectasis, and lung carcinoma. Unfor- percutaneously placed catheter and instillation of a
tunately, embolotherapy has not been effective in combination of amphotericin B and N-acetylcysteine
permanently controlling massive hemoptysis associ- (Mucomist). In one instance, instillation of aminoca-
ated with pulmonary aspergilloma, probably because proic acid (Amicar) was also employed. This article
of the presence of a massive collateral 13 describes our technique, method of treatment, and
While aspergillomas can develop in any form of cystic long-term results.
lung disease, the most common underlying conditions
MATERIALS AND METHODS
are sarcoidosis or healed cavitary tuberculosis, often
resulting in lesions in the upper lung fields. Through Four patients with aspergilloma were treated for six episodes of

the associated pleural adhesions, the mycetoma cavity hemoptysis from 1983 to 1987. There were three men and one
woman, with a mean age of 54 years (range 48 to 63 years).
wall often receives a rich extrathoracic blood supply
Underlying lung diseases were sarcoidosis in three and bullous lung
from the axillary and subclavian arteries, in addition disease in one. Patient data are summarized in Table 1. Each patient
had a chest roentgenogram documenting an upperlobe intracavitary
*Department of Radiology, Hospital of the University of Pennsyl-
vania, Philadelphia, and the tCardiovascular-Pulmonary Division
mycetoma from three months to ten years prior to admission. Serum
of the Department of Medicine, Hospital of the University of Aspergillus precipitins were positive in each of the patients; three
Pennsylvania, Philadelphia. of the four patients had sputum or percutaneous aspirates or both
Manuscript received September 18, 1987; revision accepted March from which Aspergillus species were cultured. All patients had
13.
severely compromised pulmonary function, with forced vital capac-
Reprint requests: DrMcLean, Hospital, University of Pennsylvania,
Anglo-Interventional Radiology, 3400 Spruce Street, Philadelphia ity <50 percent and resting PaO2 <80 mm Hg. Each presented
19104 with recurrent, persistent hemoptysis. One patient with bilateral

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aspergillomas had three episodes of massive hemoptysis (600 ml results of bronchoscopy. Patients were examined under fluoroscopy
blood expectorated/24 h), which required treatment of each cavity to determine the most direct route from the skin into the cavity,
on separate occasions, once on the left and twice on the right and the appropriate area was then prepared and draped in sterile
Because of continued bleeding, poor pulmonary reserve, and fashion. On five occasions, an anterior approach via the first, second
high surgical risk, these patients were referred to the Angiography/ or third intercostal space was used while on one occasion, a posterior
Interventional Radiology section for therapy. Each patient first apical approach was required. Following local anesthesia, the cavity
underwent fiberoptic bronchoscopy to determine the location of was punctured under fluoroscopic guidance with either an 18-gauge
bleeding. In every case, it was possible tojocalize the site of active Seldinger needle or 20-gauge Chiba needle. A portion ofthe cavity
hemorrhage. Percutaneous treatment was considered only if a contents was aspirated and sent for routine bacterial, fungal cultures,
solitary mycetoma was identified on routine posteroanterior and KOH, and Gram stains. The percutaneous tract was dilated, and a
lateral chest roentgenography in an area which corresponded to the 10 to 12 French Ring-McLean sump catheter (Cook, Inc. Blooming-

Table 1-Patients with Aspergillomas and Hemoptysis

Hemoptysis
Patient Underlying Mycetoma Vol/24 hr Drainage Total Dose
No. Age/Sex Disease Location Site (Bronch) Catheter Used Amphotericin Results Long-Term Follow-up

la* 49/F Sarcoidosis LUL 600 ml; LUL 12 F Ring-McLean 500 mg Hemoptysis ceased Vide infra
sump by 48 hr; myce-
toma cleared (
seven days
(see case report)
lb 49/F Sarcoidosis RUL 600 ml; 12 F Ring-McLean 800 mg Hemoptysis ceased Only minor hemopty-
RUL- sump within seven sis for 54 months,
posterior days; cavitary then had another
seg. mass/mycetoma episode of massive
decreased in size hemoptysis (vide
over three weeks infra)
( see case report).
ic 54/F Sarcoidosis RUL 500 ml; RUL 12 F Ring-McLean 750 mg Initial treatment
sump with aminoca-
proic acid; mas-
sive hemoptysis
ceased then re-
curred five days
later; additional
amino-caproic
acid then ampho-
tericin B; no fur-
ther bleeding
over two months
( see case report).
2 57/M Sarcoidosis RUL 100 ml; RUL 12 F Ring-McLean 500 mgt Hemoptysis ceased Readmitted on three
sump within 48 hrs; occasions (7/83-11/
mycetoma 85) for exacerbation
cleared within ofasthma (associ-
four weeks ated with allergic
bronchopulmonary
aspergillosis); no
further hemoptysis
or mycetoma over
4.5 years
3 63/M Sarcoidosis LUL 100-200 ml; 8 F Pigtail catheter 500 mg Hemoptysis ceased. At two years, readmit-
(History with 24 hrs; my- ted with recurrent
of cetoma cleared hemoptysis due to
asbestos within two weeks endobronchial
exposure) mass; symptoms re-
solved in one week;
lost to follow-up
4 48/M Bullous lung LUL 50-100 ml; 8.5 F Cope loop 690 mg No hemoptysis fol- No further hemopty-
disease LUL nephrostomy lowing catheter sis at 12 months
catheter placement; myce-
toma decreased
in size over three
weeks

4a indicates admission number 1; b, admission number 2; and c, admission number 3.


tMinimum dose; catheter fell out during period as outpatient.

1226 Severe Hemoptysis Associated with Pulmonary Aspergilloma (Shapiro at a!)

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ton, IN), pigtail catheter, or an 8.5 French Cope nephrostomy patient in the right lateral decubitus position, rapidly
catheter was advanced into the cavity. The catheter was then capped
replacing blood losses and by performing nasotracheal
and sutured to the skin.
intubation with selective catheterization of the left
In the first two patients, the catheters were maintained on
continuous low pressure suction except during installation of medi- mainstem bronchus. After stabilization in the medical
cation. We subsequently modified this approach, using only inter- intensive care unit, intracavitary therapy was success-
mittent periods of low wall suction (40 to 60 cmH2O) as described fully completed (see case report).
below.
In three instances (Table 1, patients ib, ic, and 4),
On the first day ofcatheter placement, a test dose of amphotericin
patients received total doses of 800 mg, 750 mg, and
B (5 mg diluted in 20 ml D5W) was instilled slowly into the cavity
with the patient in the ipsilateral decubitus position. The position 690 mg of amphotericin B in an attempt to clear the
of the patient which minimized coughing was determined, and the mycetoma. In each case, the intracavitary mass de-
patient was monitored carefully for any untoward reactions. creased in size but did not completely resolve after
For the remainder of the treatment period, 40 to 50 mg of
three weeks. The roentgenographic appearance of
amphotericin B dissolved in 10 to 20 ml of D5W was instilled over
these intracavitary masses has remained stable during
three to five minutes each morning. The catheter was then capped.
Each afternoon, approximately 8 to 12 hours following amphotencin
two months to four years offollow-up. In treating three
instillation, N-acetylcysteine (Mucomist, 10 percent solution, 10 ml additional mycetomas (Table 1, patients la, 2 and 3),
dissolved in 10 ml 0.9% saline) was slowly injected into the cavity. a total dose of 500 mg of amphotericin B was instilled
N-acetylcysteine was added to the treatment regimen to facilitate
with complete clearing of the cavity within one to four
dissolution of the fungus ball and to help in clearing debris. The
weeks. Although all patients manifested a transient
catheter was placed on low continuous wall suction (20 cmH2O) two
hours after administration of N-acetylcysteine and maintained increase in sputum production with initiation of ther-
overnight. When necessary, the patients were premedicated with apy, acute hemoptysis ceased completely within two
acetaminophen for fever, diphenhydramine hydrochloride (Bena- to eight days. Patient 1 required daily premedication
dryl) for urticaria, andlor codeine for excessive coughing during
with diphenhydramine and acetaminophen for fever
subsequent treatments. Because of massive, life-threatening bleed-
during amphotericin B infusion, while patient 4 re-
ing in one patient (see case report), intracavity instillation of
aminocaproic acid (5 g in 20 ml D5W) was also used in addition to quired daily codeine premedication for cough sup-
amphotericin B and N-acetylcysteine. pression. N-acetylcystemne was eliminated and Amicar
Intracavitary therapy was continued until hemoptysis had ceased was added to the treatment regimen of patient lc
and a minimum total dose of 500 mg amphotericin B had been
because of recurrent hemoptysis during her most
given. Serial chest roentgenograms were obtained biweekly to check
recent course of therapy. No patient showed evidence
the catheter position and status of the cavity. At the conclusion of
the treatment period (10 to 20 days), the catheter was removed of renal toxicity or other side-effects.
under fluoroscopic guidance, and a sterile dressing was placed over Patients were followed for one to 54 months post-
the site. treatment (Table 1). Two patients required hospitali-
zation for recurrent hemoptysis at 2, 24, and 54
RESULTS
months, respectively. In the first case, hemoptysis was
Six episodes of acute hemoptysis secondary to an self-limited, apparently secondary to bacterial super-
aspergilloma were treated with percutaneous intracav-
itary instillation of amphotericin B and N-acetylcys-
teine. Table 1 contains treatment data summarized.
In one case (Table 1, patient la), prior bronchial artery
embolization was performed but was unsuccessful in
controlling hemoptysis from a left upper lobe myce-
toma. During another course of therapy in this patient
(Table 1, patient ic), aminocaproic acid was added to
the regimen to control intermittent massive hemop-
tysis shortly after initial catheter placement.
Catheter insertion was completely uneventful in
four of the six placements, and none of the patients
experienced pneumothorax with cavity puncture.
However, in two patients, complications developed.
One patient experienced transient, severe broncho-
spasm following contrast injection into the cavity which
was successfully treated with nasal oxygen. Following
this experience, we no longer routinely inject contrast
into the cavity. The other patient developed massive
hemoptysis with placement of a stiff guidewire into a FGuRE 1. Chest x-ray film (posteroanterior view, March 1983).
Bilateral upper lobe cavities; mycetoma in right cavity, air.fiuid level
right upper lobe cavity. This problem was treated in left cavity with adjacent pleural thickening; scarring secondary
successfully by administering oxygen, placing the to sarcoidosis.

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Ring-McLean sump via an anterior approach. Insertion ofthe guide
wire into the cavity provoked an episode ofacute massive hemoptysis
requiring emergency nasotracheal intubation with selective cathe-
terization of the left mainstem bronchus and transfusion of eight
units of packed red blood cells. The patient was stabilized in the
medical intensive care unit, but because ofcontinued heavy bleeding
from the cavity over the next 12 hours (evidenced by a drop in
hemoglobin of 3 g/dl), intracavitary aminocaproic acid (5 g in 20 ml
D5W) was instilled via the catheter as suggested by Fernandez.21
This was associated with a prompt cessation of bleeding and a
stabilization of her hemoglobin level, allowing extubation. One day
after the bleeding had stopped, the standard course of amphotericin
B and N-acetylcysteine was begun. She remained stable for four
days, when she had another episode ofmassive hemoptysis requiring
intubation and transfusion. Five grams of aminocaproic acid were
again instilled with rapid cessation of bleeding. One day after
stabilization, she resumed standard intracavitary therapy. She had
one more episode of hemoptysis (approximately 100 ml) four days
later (at a total dose of amphotericin B of 500 mg). This was treated
successfully with one instillation of 5 g of aminocaproic acid. She
received an additional 250 mg of amphotencin B (total dose 750
mg) without further instillation of N-acetylcysteine which seemed
to be inducing some coughing. After completing her course of
intracavitary therapy, the catheter was pulled without complication
and the patient has remained stable, without further hemoptysis for
two months (Fig 5).

DISCUSSION
FIGURE 3. Twelve-French left percutaneous sump catheter in place;
communication with LUL bronchus following contrast medium Although the treatment of choice for patients with
injection.
symptomatic pulmonary aspergilloma is surgical re-
mg of amphotericin B was instilled over 20 days. Although there section of the involved segments, this therapy suffers
was incomplete resolution of the RUL mycetoma, the patient was
from several drawbacks. The most significant of these
symptomatically improved, with no further hemoptysis. The cathe-
ter was removed, and she was discharged.
is the very high operative morbidity and mortality
Over the next three years, she experienced occasional bouts of which occurs in the setting of reduced pulmonary
coughing with blood-streaked sputum and was hospitalized once for reserve and especially when diffuse underlying disease
bacterial superinfection of the LUL cavity associated with mild, is present. 1-12,22,23 Israel et al2 reviewed their surgical
self-limited hemoptysis.
experience with aspergillomas in patients with sar-
Fifty-four months following initial therapy ofthe RUL mycetoma,
the patient presented again with massive hemoptysis. Emergency
coidosis who had severely compromised pulmonary
bronchoscopy revealed bleeding from the RUL. Intracavitary ther- function, as defined by FVC and maximum breathing
apy was again initiated in the RUL cavity by placing a 12-French capacities below 50 percent and resting PaO2 <80 mm

F1;uRE 4. Chest x-ray film (posteroanterior view, seven days FIGURE 5. Chest x-ray film (posteroanterior view; five years post-
p()stdramage). Contents of LUL cavity have disappeared; RUL drainage). Note bilateral upper lobe cavities. Small mass persists in
mycetoma persists. RUL cavity; LUL cavity remains clear.

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with no evidence ofbronchopleural-cutaneous fistulae. REFERENCES

The reasons for the rapid effectiveness of this ther- 1 Glimp BA, Bayer AS. Pulmonary aspergilloma: diagnostic and
apy are not entirely clear. The initial rapid response therapeutic considerations. Arch Intern Med 1983; 143:303-08

to amphotericmn B instillation may be related to its 2 Israel HL, Lenchner GS, Atkinson GW. Sarcoidosis and asper-
gilloma: the role of surgery. Chest 1982; 32:430-32
irritative properties and sclerosing ability rather than
3 Garvey J, Crastnopol P, Weisz D, Wisoff C. Surgical treatment
its antifungal action. It is believed that the bleeding ofpulmonary aspergillomas. NY State J Med 1978; 78:1722-25
associated with aspergilloma is due to extensive cap- 4 Garvey J, Crastnopol P, Weisz D, Khan F. The surgical treatment
illary oozing, rather than large vessel disruption. It of pulmonary aspergilloma.s. J Thorac Cardiovasc Surg 1977;

seems most likely that the combination of amphoteri- 74:542-47


5 Karas A, Hankins JR, Altar 5, Miller JE, McLaughlin JS.
cm B and N-acetylcysteine acts by first sclerosing the
Pulmonary aspergillosis: an analysis of 41 patients. Ann Thorac
rich capillary lining ofthe cavity and then dissolving Surg 1976; 22:1-7
the fungus ball (allowing its removal by suction). By 6 Saab SB, Almond C. Surgical aspects ofpulmonary aspergillosis.
sterilizing the cavity of its fungal elements, the source J Thorac Cardiovasc Surg 1971; 68:455-60
of capillary irritation may be eliminated. The mecha- 7 Solit RW, McKeown JJ Jr. Smullens 5, Fraimow W. The surgical
implications of intracavitary mycetomas (fungus balls). J Thorac
nism of action of aminocaproic acid in this setting is
Cardiovasc Surg 1971; 62:411-22
unclear. It is known that amino caproic acid inhibits 8 EastridgeCE, YoungJM, Cole F, Gourley R, PateJW. Pulmonary
fibnnolysis principally via inhibition of plasmmnogen aspergillosis. Ann Thorac Surg 1972; 13:397-403
activating substances. It has been postulated that 9 Soltanzadeh H, Wychulis AR, Sadr F, Bolanowski PJ. Surgical

extravascular clots which have formed in vivo and treatment of pulmonary aspergilloma. Ann Surg 1977; 186:13-
16
have incorporated aminocaproic acid may not undergo
10 Aslam PA, Eastridge CE, Hughes FA Jr. Aspergillosis of the
spontaneous lysis.2 lung-an eighteen-year experience. Chest 1971; 59:28-23
The optimal approach to the patient with mycetoma 11 Jewkes J, Kay PH, Paneth M, Citron KM. Pulmonary aspergil-
and pulmonary hemorrhage is unclear. Spontaneous loma: analysis ofprognosis in relation to haemoptysis and survey
lysis of mycetoma has been reported in up to 10 oftreatment. Thorax 1983; 38:572-78
12 Mattox KL, Guinn GA. Emergency resection for massive
percent of patients. However, the incidence of spon-
hemoptysis. Ann Thorac Surg 1974; 17:377-83
taneous lysis or recurrence ofbleeding once an episode 13 Remy J, Arnaud A, Fardou H, Giraud R, Voisin C. Treatment of
of significant hemoptysis has occurred is unknown. hemoptysis by embolization of bronchial arteries. Radiology
With persistent , progressively increasing frequency 1977; 122:33-37

and amount of hemoptysis, intervention must be 14 Uflacker R, Kaemmerer A, Neves C, Picon PD. Management
of massive hemoptysis by bronchial artery embolization. Radi-
considered. In patients with adequate pulmonary
ology 1983; 146:627-34
reserve and hemoptysis associated with an aspergil- 15 Hammerman KJ, Sarosi GA, Tosh FE. Amphotericin B in the
loma, surgical resection remains the definitive therapy. treatment of saprophytic forms of pulmonary aspergillosis. Am
However, in patients with severe, chronic respiratory Rev Respir Dis 1974; 109:57-62

insufficiency and limited pulmonary reserve with 16 Hamamoto T, Watanahe K, Ikemoto H. Endobronchial mico-
nazole for pulmonary aspergilloma. Ann Intern Med 1983;
diffuse or localized underlying lung disease, intracav-
98: 1030
itary therapy with amphotericin B, N-acetylcyste- 17 Ramirez-R J. Pulmonary aspergilloma: endobronchial treatment.
me aminocaproic acid offers an alternative for the N EngI J Med 1964; 271:1281-85
18 Adelson HT, Malcolm JA. Endocavitary treatment of pulmonary
treatment of hemoptysis. The approach offers a num-
mycetomas. Am Rev Respir Dis 1968; 98:87-92
ber of advantages. There is no loss of lung function.
19 Hargis JL, Bone RC, Stewart J, Rector N, Hiller FC. Intracav-
Rapid evacuation of intracavitary blood and fungal itary amphotericin B in the treatment ofsymptomatic pulmonary
debris is possible through the catheter. The technique aspergillomas. Am J Med 1980; 68:389-94

can be performed quickly, and in our experience, was 20 Krakowka P. Traczyk K, Walczak J, Halwey H, EIsner Z, Pawlick
L. Local treatment of aspergilloma of the lung with a paste
associated with minimal morbidity and no mortality.
containing nystatin or amphotericin B. Tubercle (London) 1970;
Hemoptysis was controlled in all episodes, including 51: 184-91
episodes ofintermittent massive hemoptysis occurring 21 Fernandez NA. Intracavitary anlinocaproic acid for massive
pulmonary hemorrhage. Chest 1984; 85:839
shortly after initial catheter placement. Most impor-
22 Tomlinson JR. Sahn SA. Aspergilloma in sarcoid and tubercu-
tantly, this approach offers another therapeutic option losis. Chest 1987; 92:505-08
for a group of patients with an otherwise poor prog- 23 Butz RO. Aspergilloma in sarcoid and tuberculosis (editorial).
nosis. Chest 1987; 92:392
24 Kaplan J, Johns CJ. Mycetomas in pulmonary sarcoidosis: non-
ACKNOWLEDGMENTS: We would like to thank Dr. Howard
surgical management. Johns Hopkins Med J 1979; 145: 157-61
Eisen (Hospital of the University of Pennsylvania) for his assistance
in this study and Mr. Henry Way for his skillful preparation of the 25 Hammerman KJ, Christianson CS, Huntingdon I, Hurst GA, et
manuscript. al. Spontaneous lysis of aspergillomata. Chest 1973; 64:697-99

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Hg. Each ofthe seven patients who underwent surgical a thoracotomy was performed for a symptomatic left
resection for intractable bleeding or repeated severe upper lobe aspergilloma. Lung resection could not be
hemorrhages required intensive respiratory care for accomplished due to extensive radiation fibrosis and
weeks or months. Six patients experienced prolonged scarring. A Foley catheter was placed in the cavity
air leaks and two developed empyemas despite an during surgical exploration. Intracavitary and systemic
attempt to reduce the frequency ofthese complications amphotericin B were initially given; however, the
by performing a tailoring thoracoplasty in five of these patient developed massive bleeding from the cavity,
patients. Three patients eventually died of postopera- which was eventually controlled with instillation of
tive respiratory failure. 5 g of aminocaproic acid.
This experience is echoed in a more recent study Each of our patients was referred for percutaneous
by Tomlinson and Sahn who examined the outcomes placement of an indwelling intracavitary catheter be-
of 28 patients with aspergillomas. In this study, the cause of persistent or massive hemoptysis superim-
predisposing lung disease in 14 paients was tubercu- posed upon severe, diffuse underlying lung disease.
losis (with relatively localized disease), while the The risk of surgical therapy was believed to be
remaining 14 patients had sarcoidosis with more excessive and, as illustrated in the case report, bron-
diffuse lung involvement. Ten of 13 tuberculosis pa- chial artery embolization had proven to be ineffective
tients had surgical resection of their aspergillomas in controlling acute hemoptysis.
because of persistent bleeding. Eight underwent lo- We instilled amphotericin B in larger doses than
bectomy with satisfactory results, while two patients previously 19 Moreover, we combined this
with planned lobectomies underwent pneumonec- with instillation of N-acetylcysteine in an attempt to
tomy because of extensive pleural and parenchymal clear the mass of fungus, fibrin, mucus, and blood
fibrosis. These two patients died in the postoperative which comprise the fungus ball. In one case, amino-
period from respiratory failure demonstrating that caproic acid was added to the regimen to control acute
surgery may be hazardous even with localized dis- massive hemoptysis. Three of five mycetomas showed
ease ifthe procedure has to be extended. Surgery was complete resolution, and there was a decrease in size
not offered to any of the patients with sarcoidosis of the remaining two. Regardless of the status of the
despite the occurrence of massive hemoptysis in two mycetoma, acute hemoptysis resolved in each case
of them. These two patients were treated with bron- over two to eight days. Even episodes of massive life-
chial artery embolization for control of bleeding. Both threatening hemoptysis could be treated with intra-
died within six weeks of the procedure: one with cavitary therapy in nonsurgical candidates.
recurrent hemoptysis and the other with progressive Fluoroscopically guided percutaneous placement of
respiratory failure. Despite these results, the authors the intracavitary catheters was not accompanied by
recommend embolization as the only option to control the development of a pneumothorax in any case,
bleeding in patients with diffuse lung involvement. probably because of extensive pleural adhesions. We
Our results suggest that intracavity therapy may be experienced two complications during catheter inser-
a viable therapeutic alternative to control hemoptysis tion. In one patient, transient bronchospasm devel-
in this group of high risk patients. While this study oped after instillation ofcontrast media into the cavity,
was not a controlled trial, and the natural history of a procedure we now avoid. More worrisome was our
hemoptysis in pulmonary aspergillomas is rather un- most recent patient, who developed an episode of
predictable,24rs we were able to successfully treat all massive hemoptysis during guidewire placement. This
six episodes of bleeding without surgery, thus avoiding bleeding was of such magnitude that it necessitated
the all-too-frequent postoperative complications. Each emergency nasotracheal intubation and selective
patient left the hospital within three weeks of their placement ofthe endotracheal tube in the contralateral
episode of hemoptysis without further loss of lung mainstem bronchus. In view ofthis recent experience,
function or any permanent complications. we now recommend close respiratory and hemody-
There have been several reports describing the use namic monitoring during the procedure, with oxygen,
of intracavitary therapy to treat pulmonary aspergil- suction, and equipment for nasotracheal intubation
l20 Amphotericin B, as well as sodium iodide, readily available. An anesthesiologist and/or a pulmo-
have been instilled by endobronchial catheters, re- nary physician capable of providing immediate venti-
peated transthoracic puncture, and indwelling trans- latory support is also suggested.
thoracic catheters. In these reports, the most common In most patients, the daily instillations of amphoter-
indications for therapy have been persistent cough, icin B and N-acetylcysteine were well tolerated.
weight loss, fever, progressive roentgenographic Codeine, diphenhydramine, or acetaminophen pre-
changes, and intermittent A transtho- medication were occasionally used for control of minor
racic approach for the control of acute hemoptysis has symptoms. In all patients, the percutaneous tract
been described in only one case report.2 In this case, closed within one week of removal of the catheter,

1230 Severe Hemoptysis Associated with Pulmonary Aspergilloma (Shapiro et a!)

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with no evidence ofbronchopleural-cutaneous fistulae. REFERENCES

The reasons for the rapid effectiveness of this ther- 1 Glimp BA, Bayer AS. Pulmonary aspergilloma: diagnostic and
apy are not entirely clear. The initial rapid response therapeutic considerations. Arch Intern Med 1983; 143:303-08

to amphotericmn B instillation may be related to its 2 Israel HL, Lenchner GS, Atkinson GW. Sarcoidosis and asper-
gilloma: the role of surgery. Chest 1982; 32:430-32
irritative properties and sclerosing ability rather than
3 Garvey J, Crastnopol P, Weisz D, Wisoff C. Surgical treatment
its antifungal action. It is believed that the bleeding ofpulmonary aspergillomas. NY State J Med 1978; 78:1722-25
associated with aspergilloma is due to extensive cap- 4 Garvey J, Crastnopol P, Weisz D, Khan F. The surgical treatment
illary oozing, rather than large vessel disruption. It of pulmonary aspergilloma.s. J Thorac Cardiovasc Surg 1977;

seems most likely that the combination of amphoteri- 74:542-47


5 Karas A, Hankins JR, Altar 5, Miller JE, McLaughlin JS.
cm B and N-acetylcysteine acts by first sclerosing the
Pulmonary aspergillosis: an analysis of 41 patients. Ann Thorac
rich capillary lining ofthe cavity and then dissolving Surg 1976; 22:1-7
the fungus ball (allowing its removal by suction). By 6 Saab SB, Almond C. Surgical aspects ofpulmonary aspergillosis.
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16
have incorporated aminocaproic acid may not undergo
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insufficiency and limited pulmonary reserve with 16 Hamamoto T, Watanahe K, Ikemoto H. Endobronchial mico-
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debris is possible through the catheter. The technique aspergillomas. Am J Med 1980; 68:389-94

can be performed quickly, and in our experience, was 20 Krakowka P. Traczyk K, Walczak J, Halwey H, EIsner Z, Pawlick
L. Local treatment of aspergilloma of the lung with a paste
associated with minimal morbidity and no mortality.
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ACKNOWLEDGMENTS: We would like to thank Dr. Howard
surgical management. Johns Hopkins Med J 1979; 145: 157-61
Eisen (Hospital of the University of Pennsylvania) for his assistance
in this study and Mr. Henry Way for his skillful preparation of the 25 Hammerman KJ, Christianson CS, Huntingdon I, Hurst GA, et
manuscript. al. Spontaneous lysis of aspergillomata. Chest 1973; 64:697-99

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