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Saturday, June 14, 2008

Gardeners: Be Cautious Of These Fungal Spores

A previously healthy man died after inhaling fungal spores from dead plant material while gardening in May 2007, and is discussed in a Case Report released on June 13, 2008 in The Lancet.

The man, 47 years old, was considered in good health, though he was a professional welder and smoked approximately ten cigarettes per day. He was admitted after one week presenting a sputum-producing cough, chest pain, and worsening shortness of breath. Running a fever of 100.4°F (38°C,) he had a low lymphocyte and neutrophil count. He also had coarse crackles in his lungs, and his chest radiography showed irregular nodules.

Assumed to have community-acquired pneumonia, he was treated with intravenous co-amoxiclav and clarithromycin, but when his symptoms worsened, a third antibiotic, flucloxacillin, was administered. In the next day, he became so short of breath that even with supplementary oxygen he needed to be transferred to the intensive care unit (ICU.) In the ICU, it became clear from blood gas measurements that despite intubation and ventilation, adequate gas exchange was not being provided in his tissues. Additionally, he showed signs of serious sepsis.

At this point, an HIV test was negative. However, two sputum samples cultured the fungus Asperillus fumigatus. According to the authors, "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." Treatment with intravenous liposomal amphotericin B was started.

The man was subsequently transferred to another unit for extracorporeal membrane oxygenation (ECMO,) which is similar to being supported by a heart-lung machine. Upon his arrival, despite the ECMO treatment, his blood pressure remained too low and he developed kidney failure. Although a continuous dialysis was initiated, as his condition worsened, escalation of treatment was considered inappropriate. After 72 hours, ECMO was terminated and he died soon after. The diagnosis of aspergillosis was confirmed through a laboratory analysis of blood samples.

Spores of aspergillus are often found on decaying plant matter, and inhalation of these spores can cause several different types of aspergillosis. These can range from acute and invasive, like in the aforementioned patient, to chronic and necrotizing.

The authors conclude with a statement regarding how this patient was an unusual example of aspergillosis, and that his case may have been influenced by immunosuppression. "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 say.

Additionally, they add, immediate antifungal treatment is essential in these cases: "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."

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