The tragic case of a previously healthy man who died after inhaling fungal spores from dead plant material while gardening is highlighted in a Case Report in this week's edition of The Lancet, authored by Dr David Waghorn, Wycombe Hospital, Buckinghamshire Hospitals NHS Trust, High Wycombe, UK and colleagues.
During May 2007, the 47-year-old man was admitted with a 1-week history of sputum-producing cough, chest pain, and increasing shortness of breath. He worked as a welder, smoked around 10 cigarettes per day, but had no other medical history and had been in good health. He had a fever (38°C) and coarse crackles throughout his lungs -- and chest radiography showed various irregular nodules. He was treated for assumed community-acquired pneumonia using intravenous co-amoxiclav and clarithromycin, but the symptoms worsened and a third antibiotic, flucloxacillin, was administered. Within 24 hours, the man soon became so short of breath, despite supplementary oxygen, he was transferred to the intensive care unit (ICU). In ICU, blood gas measurements showed that intubation and ventilation were not providing adequate gas exchange for his tissues. He also had signs of overwhelming sepsis.
The man was then referred to a regional specialist unit for a treatment called extra-corporeal membrane oxygenation (ECMO). Before his transfer, an HIV test was negative, but the fungus Asperillus fumigatus had grown from two sputum samples. The authors say: "On closer questioning, the patient's partner revealed that his symptoms had started less than 24h after he had dispersed rotting tree and plant mulch in the garden, where clouds of dust had engulfed him."
To treat this fungal infection, treatment with intravenous liposomal amphotericin B was started before the man was moved to the regional unit. On arrival there, less than 12h after ICU admission, he received the ECMO treatment but his blood pressure remained too low and he developed acute kidney failure. Continuous dialysis was started, but his condition worsened and further treatment escalation was considered inappropriate. ECMO was withdrawn after 72 hours and the man died shortly thereafter. The diagnosis of aspergillosis was confirmed by analysis of blood samples at the Mycology Reference Centre, Leeds.
Aspergillus spores are often found on decaying plant matter. Inhalation of spores can cause various types of aspergillosis, which can be acute and invasive, as in this patient, or chronic and necrotising. The authors conclude: "Unlike most patients with acute, invasive, aspergillosis, our patient did not seem to be immunosuppressed; however, smoking and welding could have damaged his lungs, increasing his vulnerability. Since he died so quickly, we cannot exclude the possibility that he had an undetected immunodeficiency. Acute aspergillosis after contact with decayed plant matter is rare, but may be considered an occupational hazard for gardeners."
They add that prompt treatment with an appropriate antifungal agent is vital in such cases. They say: "Although liposomal amphotericin B has been used in such cases, and was the recommended treatment of choice within our hospital trust at the time of this case, more recent guidelines suggest voriconazole may currently be the optimum empirical therapy."
For Dr David Waghorn, Wycombe Hospital, Buckinghamshire Hospitals NHS Trust, High Wycombe, UK please contact Jon Fisher, Press Office: T) +44 (0) 1494 734840 / +44 (0) 7880 982099 E) jon.fisher@buckshosp.nhs.uk; david.waghorn@buckshosp.nhs.uk
http://www.eurekalert.org/jrnls/lance/Case%20report%20p2056%20June%2014.pdf
Journal
The Lancet