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The possibilities of computed tomography in paecilomycosis of lungs.

Introduction

For the last years there has been keen interest of physicians around the world to the study of fungal diseases. This is explained with the sharp increase of the mycosis development against a background of the new medical technologies introducing in practice (difficult cavitary surgical operations, transplantation of internal organs, long-term using of new antibiotics, steroids and immunosuppressive medications) and worsening of ecology. Thus, the significance of fungal infections problem has increased due to reverse side process of technological progress in modern medicine (Askarov et al., 2009; Lesovoi et al., 2008; Popov et al., 2009). Paecilomyces soil fungi, new type of pathogen earlier considered as nonpathogenic, draws attention as etiological factor of broncho-pulmonary pathology on the territory of Uzbekistan, (Abduhalik-zade, 1997; Ahunova, 2000; Ahunova, 2005; Malikova et al., 2006; Muetdinova, 2001).

Fungal infection caused by Paecilomyces is one of the youngest "etiological forms" of the man's affection. Morbidity of people of different ages from this fungi is increasing, and the disease originating due to this agent is called paecilomycosis. Nowadays, in spite of the many challenges associated with the epidemiology and clinic, immunologic diagnosis and therapy of this pathology, radiodiagnosis hitherto remains little explored. The published studies concern mainly of the descriptive character of roentgenologic changes in clinical observations. Sufficient data to determine the character and prevalence of pathological process in lungs were not found, despite of general validity of discovered changes had been received during the classical X-ray examination; accurate specification is needed. It is stipulated mostly by the limitations of this method. In our opinion, to diagnose lung injures caused by Paecilomyces fungus, clear criteria determining the use of different methods of proved visualization, computed tomography in particular (CT), must be worked out. However, neither domestic nor foreign literature cover reports on the implementation of this revolutionary technology of visualization into the diagnosis of broncho-pulmonary Paecilomyces.

The study discusses significance and opportunities for computer tomography in diagnostics of pulmonary forms of paecilomycosis; enabling to determine the nature and extent of lung lesions, as well as the incidence of the pathological process.

Materials and methods

We analyzed the results of chest CT of 56 patients with lung injures caused by Paecilomyces fungus: 15 patients with chronic obstructive bronchitis, 16 patients with recurrence pneumonia, 10 patients with exogenous-allergic alveolitis, and 15 patients with bronchial asthma. Patients were 17-59 years old and they were observed and treated in consultative polyclinic, therapeutic department and intensive care unit of Samarkand Medical Institute's clinic.

Clinical-laboratory, roentgenologic, mycological and other methods of observations diagnosed broncho-pulmonary paecilomycosis in these patients.

CT investigation was carried out by special equipment "Somatom Emotion" of "Siemens" company with 10-20 mm step of tomography. Primary standard CT investigation involved receiving of series of adjoining tomographic cuts from lung apexes to the bottom of posterior rib-diaphragm sinuses; the procedures were made with native contrast CT at the altitude of holding inhalation and pulmonary electronic window (-700 ... -800 HU). More detailed cuts (2-5 mm) with the following image reconstruction were performed to determine pathology of lung interstitial.

Results and discussion

During the study of CT images of the lung injures caused by Paecilomyces fungus, attention was paid to the structure of interstitial, alveolus, bronchus and terminal parts of the respiratory tract; angioarchitectonics, condition of lymphatic nodes and pleura, and also to the localization of changes.

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Table 1 shows evaluation of diagnostic possibilities of step-by-step CT for different types of broncho-pulmonary paecilomycosis. The table describes CT semiotics of different types of broncho-pulmonary paecilomycosis and frequency of different signs.

From the table it is evident that in broncho-pulmonary type of paecilomycosis the most frequent characteristic CT-signs are the following:

--changes of the interstitial tissue;

--mild focuses masses;

--infiltrative changes;

--changes in small bronchus and bronchioles;

--"frosted glass" symptom;

--changes in pleura and lymph nodes.

One of the common CT-signs of injures of broncho-pulmonary system in paecilomycosis is the change in lungs' interstitial tissues, which leads to the appearance of thin netting or large-looping intensification of the lung pattern (Figure 1) due to infiltration of peribronchial, interlobar and intralobular interstitial tissue. This infiltration was stipulated by inflammation or fibrosis of connective tissue, interalveolar and interlobular septum which surround the walls of bronchioles and blood vessels.

Perverted lung pattern due to pathology of interstitial tissue was established in 52 (93%) patients out of 56 (in chronic bronchitis--100%, in exogenous-allergic alveolitis--93%, in recurrent pneumonia--100% and in bronchial asthma--80%).

Analysis of CT data shows that centrolobular randomly located focal shadows are more typical sighns (40 patients, 71%) for lung lesions with fungi Paecilomyces. These centrolobular foci, corresponding to the center of the slices, tend to be the focuses of peribronchial and periarterial inflammation. Combination of centrolobular focuses with infiltrations of thin lined structure (1-2.5 mm) indicates that they belong to the terminal parts of respiratory tract. Chaotic localizing foci in the lung lobule can represent injures of the respiratory tract, intralobular interstitial and branching intralobular arteries (Figure 2).

CT-observation determined infiltrative changes (decreasing of transparence) of the lung tissue in 42 (43%) patients. Sometimes in CT, during the localization of infiltrates in the area of hilum, central part of the lungs, along broncho-respiratory tracts, these changes are manifested as conglomerate masses (Figure 3) which we can observe in fibrosis or combined focuses.

Changes in bronchus and terminal parts of respiratory tract in patients with paecilomycosis during CT-investigation are most often depicted as peribronchial infiltration (in 42 cases--76%) and fibrosis (in 21 cases--37%). In a perpendicular position to scan in broncho-respiratory structure we determine ring-shaped shadow with irregular lumen and irregular thickening of wall with adjacent transverse section of pulmonary artery (rounded soft-tissue structure) (Figure 4).

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One of the pathological manifestations, detected during CT in the terminal bronchus, are so called "air traps" (centrolobular emphysema); they represent abnormal retentions of air within lobules and can be developed by bronchiolar constriction and look like zones of high air filling.

The symptom of "frosted glass" which is one of the reliable CT-signs of lung paecilomycosis displays various pathological changes at the level of alveolus (alveolitis, presence of cellular infiltrates in the lumen of alveolus--macrophages, blood cells, lymphocytes and others). The symptom manifests itself fields like a lower intensity "milk shroud" due to decreasing of airiness (transparency) of lung (Figure 5). Our investigations determined the symptom in 10 (67%) cases of exogenous-allergic alveolitis, in 8 (50%) in cases of recurrent pneumonia, and in 6 (40%) patients in cases of bronchial asthma. "Frosted glass" reflects not only the manifestation of alveolitis and inflammatory infiltration, but also occurring of congestion in the microcirculatory bed of lung. However, this symptom differs from the pneumonic shadows where different vascular structures are distinguished on the background.

In broncho-pulmonary paecilomycosis, CT determined sometimes the symptom of "honeycomb lung"--in 5 (33%) patients with exogenous-allergic alveolitis of long-term duration. Lung tissue is replaced by cystic air spaces of 3-10 mm in the diameter; these cystic spaces are grouped and divided by the fibrous tissue replaced by interstitial tissue. Deformation and compaction of parenchymatous-interstitial structures take the form of "cell-lung"--a brush of the honeycomb type (Figure 6).

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CT observation revealed other symptoms of lung damage in paecilomycosis along with the above mentioned features: angioarchitectonic disorganization (50 cases--89%), thickening of the interlobular pleura (29 cases--52%), bronchopulmonary adenopathy and other intrathoracic lymph nodes (27 cases--48%).

The results of this study showed that in broncho-pulmonary type of paecilomycosis the CT reveals a series of general symptoms indicating the diffuse lesions of the lung parenchyma and interstitial tissue, and clarifying the stage of development of pathological process. The most frequent lung lesion cases are cellular-looping enhancement of the lung pattern due to sclerosis (infiltration, fibrosis) of interstitial tissue, apparition of small focused changes in the interstitial tissue and in the terminal bronchioles, in small blood vessels, the shadowing focuses in the lung fields and "frosted glass" zones. Other symptoms, e.g. "honeycomb lung," arise as the disease progresses and causes irreversible fibrous changes. These changes can also be determined in other interstitial and diffuse lung diseases. Therefore, during the verification of diagnosis of broncho-pulmonary paecilomycosis the main differential-diagnostic criteria must be the positive results of mycological investigation (high spherule level of Paecilomyces fungi in the blood, their presence in sputum and isolated culture of the fungus in the nutrient media), as well as the absence of other etiological factors of the lung injure.

Thus, the analyses of CT-data in determination of pathological changes in lungs in the pulmonary form of paecilomycosis demonstrated that CT has the significant potential to visualize the whole spectrum of symptoms of injures of lung tissue and allows physicians to increase the accuracy in determining the character and degree of injures; it improves substantially the accuracy in determining the nature and extent of lesions as well as the localization and prevalence of disease. Based on these obtained results we suggest that the diagnosis of broncho-pulmonary paecilomycosis should be based on the history of the disease, clinical manifestation of the disease, data of mycological investigation and computer tomography of high resolution.

References

Abduhalik-Zade, G., 1997. "The role of Paecilomyces fungi in the development of antenatal pneumonia," Doctoral dissertation, Samarkand.

Ahunova, A., 2000. "Some pathogenic mechanisms of the development of infectious-allergic bronchial asthma in pecilomycosis," Clinical medicine, Vol.9, pp.35-40.

Ahunova, A., 2005. "About the role paecilomycosis infection infection in the development of endogenous bronchial asthma," Clinical medicine, Vol.6, pp.87-91.

Alimjanova, R., Dehkan-Hodjaeva, N., 2002. "Clinical manifestation, duration and treatment of the lung injures in fungal diseases of adults," Methodic recommendations, Tashkent.

Askarov, K., Lazareva, N., Boymurodov, N., Sagieva, A. et al., 2009. "Lung mycosis as complications of basic diseases with significant changes of biochemical indexes," Collection of research works, Moscow Medical Academy named by N.M. Sechenov on problems of ecology, health, pharmacies and parasitology, pp.27-30.

Chebishev, N., Lazareva, N., Sadikov, V., Strelaeva, A., 2006. "Paecilomycosis-toxocarose bronchial asthma," Collection of research works, Moscow Medical Academy named by N.M. Sechenov on problems of ecology, health, pharmacies and parasitology, pp.3-6.

Lazareva, N., Samilina, I., Abdullaeva, N., Strelaeva, A., et al., 2006. "Antenatal paecilomycosis pneumonia transforming to sepsis," Collection of research works, Moscow Medical Academy named by N.M. Sechenov on problems of ecology, health, pharmacies and parasitology, pp.7-9.

Lesovoi, V., Liniski, A., 2008. "Mycosis of central nervous system," Problems of medical mycology, Vol.10, No1, pp.3-7.

Malikova, F., Uzakova, U., Jahongirova, H., Mansurova, S., 2006. "The role of Paecilomyces fungi in the development of toxicosis of pregnancy," Collection of research works, Moscow Medical Academy named by N.M. Sechenov on Problems of ecology, health, pharmacies and parasitology, pp.51-52.

Mingboev, M., Dehkan-Hodjaeva, N., 2001. "The investigation and treatment tactics in children with broncho-pulmonary mycosis," Methodic recommendations, Tashkent.

Muetdinova, E., 2001. "Immunomodular and genotoxic features Paecilomyces viridis fungi," PhD dissertation, Tashkent.

Popov, D., Belogorodova, N., Sedrikyan, L., 2009. "Problems of postoperative candidemia in children," Russian bulletin perinatology and pediatrics, Vol.3, pp.52-56.

Shodieva, H., 2006. "Clinical-pathogenetic characteristics of infectious-toxic cardiopathy and myocarditis in early-aged children with paecilomycosis," Doctoral dissertation, Tashkent.

Strelaeva, A., Sadikov, V., Zakirova, N., Abduhalik-Zade, G. et al., 2006. "Antenatal pneumonia paecilomycosis etiology," Allergy and immunology, Vol.7, No1, pp.57-59.

Vohidova, A., Galimova, A., Boymurodov, N., Davidan, A. et al., 2009. "Modern imaginations about the role of Paecilomyces fungi in human pathology," Collection of research works, Moscow Medical Academy named by N.M. Sechenov on problems of ecology, health, pharmacies and parasitology, pp.36-39.

ABDUSALOM ASHUROV

ROHILA JABBAROVA

Department of Radiological Diagnostic and Radiological Treatment, Samarkand Medical Institute, Uzbekistan
TABLE 1. CT-SIGNS OF THE DIFFERENT TYPES OF BRONCHO-PULMONARY
PAECILOMYCOSIS

Structure                     Signs                  Chronic
                                                 bronchitis n=10

                                                  Abs.        %
                                                 amount

Interstitial         Intensification of image      10        100
                     Centers                        8         80
                     Fibrosis                       4         40

Alveolar             "Frosted glass"               --         --
                     Emphysema                      4         40
                     Infiltration                  --         --
                     Cysts                         --         --
                     "Honeycomb                    --         --
                     lung"

Bronchus             Peribronchial                 10        100
Terminal parts of    infiltration
respirator tract     Bronchiolitis
                     Dilatation                    --         --
                     Centrolobular                 --         --
                     centers
                     Peribronchial                  6         60
                     fibrosis
                     Bronchiectasis                 4         40

Pleura               Local infiltration            --         --
                     Stratification                --         --
                     Even thickening               --         --

Disorganization of   Peripheral                    --         --
angioarchitectonic
                     Peripheral +                   4         40
                     central parts

Adenopathy of                                       6         60
lymph nodes

Localization of      Subpleural                    --         --
changes              Central                        7         70
                     Diffuse                        2         20
                     Diffuse-central                1         10

Structure                     Signs                  Exogenous-
                                                 allergic alveolitis
                                                        n=15

                                                  Abs.        %
                                                 amount

Interstitial         Intensification of image      14         93
                     Centers                       12         80
                     Fibrosis                       8         54

Alveolar             "Frosted glass"               10         67
                     Emphysema                      6         40
                     Infiltration                   4         26
                     Cysts                          2         13
                     "Honeycomb                     5         30
                     lung"

Bronchus             Peribronchial                 13         87
Terminal parts of    infiltration
respirator tract     Bronchiolitis
                     Dilatation                    10         67
                     Centrolobular                 --         --
                     centers
                     Peribronchial                  5         33
                     fibrosis
                     Bronchiectasis                 4         27

Pleura               Local infiltration             4         27
                     Stratification                --         --
                     Even thickening               11         73

Disorganization of   Peripheral                    10         67
angioarchitectonic
                     Peripheral +                   5         33
                     central parts

Adenopathy of                                       8         53
lymph nodes

Localization of      Subpleural                     7         47
changes              Central                       --         --
                     Diffuse                        3         20
                     Diffuse-central                5         33

Structure                     Signs                  Recurrent
                                                   pneumonia n=16

                                                  Abs.        %
                                                 amount

Interstitial         Intensification of image      16        100
                     Centers                       11         69
                     Fibrosis                       4         27

Alveolar             "Frosted glass"                8         50
                     Emphysema                     --         --
                     Infiltration                  16        100
                     Cysts                         --         --
                     "Honeycomb                    --         --
                     lung"

Bronchus             Peribronchial                 10         63
Terminal parts of    infiltration
respirator tract     Bronchiolitis
                     Dilatation                     6         38
                     Centrolobular                 --         --
                     centers
                     Peribronchial                 13         82
                     fibrosis
                     Bronchiectasis                 6         38

Pleura               Local infiltration            --         --
                     Stratification                --         --
                     Even thickening                6         38

Disorganization of   Peripheral                    13         81
angioarchitectonic
                     Peripheral +                   3         19
                     central parts

Adenopathy of                                       4         25
lymph nodes

Localization of      Subpleural                    10         63
changes              Central                        4         25
                     Diffuse                       --         --
                     Diffuse-central                2         13

Structure                     Signs                  Bronchial
                                                      asthma
                                                       n=15

                                                  Abs.        %
                                                 amount

Interstitial         Intensification of image      12         80
                     Centers                        9         60
                     Fibrosis                       8         53

Alveolar             "Frosted glass"                6         40
                     Emphysema                      3         20
                     Infiltration                   4         26
                     Cysts                         --         --
                     "Honeycomb                    --         --
                     lung"

Bronchus             Peribronchial                  9         60
Terminal parts of    infiltration
respirator tract     Bronchiolitis
                     Dilatation                    14         93
                     Centrolobular                 --         --
                     centers
                     Peribronchial                  6         40
                     fibrosis
                     Bronchiectasis                 7         47

Pleura               Local infiltration             2         14
                     Stratification                --         --
                     Even thickening                6         40

Disorganization of   Peripheral                     8         54
angioarchitectonic
                     Peripheral +                   7         46
                     central parts

Adenopathy of                                       9         60
lymph nodes

Localization of      Subpleural                     4         26
changes              Central                       --         --
                     Diffuse                        7         47
                     Diffuse-central                4         26
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Author:Ashurov, Abdusalom; Jabbarova, Rohila
Publication:Medical and Health Science Journal
Article Type:Report
Date:Jul 1, 2010
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