Peter K

March 2009

A case of surgical removal of an aspergilloma.

1. History
2. Treatment
3. Considering operation
4. Operation
5. Post Operation

1. History
In 1974, I was diagnosed with a large pneumathorax, a collapsed right lung. Attempts to inflate it failed and after several weeks in hospital, with a vacuum pump attached, I was then transferred to the Copenhagen University hospital. Here, I underwent an operation that ended up in rather a mess. It appeared that my blood was hesitant to coagulate, and over a week I was re-operated four times, received much blood and ended up in a respirator where I spent two weeks while the internal bleeding slowly came to an end.

The recovery period was long. After three months I went back to work, but it was more than a year before I was physically back to where I had been.

One thing I did not know – the surgery had left a small cavity, about 27 cm in diameter, in my upper right lung lope. Apart from another spontaneous pneumathorax in my left lung, which this time was successfully fixed by another open thorax surgery in 1986, I had no symptoms to speak of for a long time. I went back to exercising, travelled and worked hard with long hours. It was not until the summer of 2004, that I received the first signs that something was not quite as it should be.

2. Treatment
I was working in California at the time, and in the late summer of 2004 I developed what I and my GP thought was a seasonal allergy. I coughed, producing greenish thick sputum. It got worse, and the colour changed slowly to brownish. Then, on Christmas day of 2004 I had my first haemoptysis. It came spontaneously; my mouth filled with blood and I had to go to the bathroom and cough up fresh blood for a few minutes. Then it wore off.

My wife and I went to the emergency reception at our local hospital, where I had another haemoptysis while waiting to be seen by a doctor. After that I was sent home and asked to see my GP the next morning. However, during

the night I had another two incidents, went again to the hospital, and this time I was admitted – to isolation in a room with elevated air pressure. When nurses came in, or my wife came in, they had to wear masks. The indication, of course, was TB. Lab tests, however, turned out to be negative, and after a few days people no longer wore protective gear when seeing me. I was given heavy doses of antibiotics intravenously for several days, and then sent home.

Things went well throughout January 2005, but then, in February, I had another spontaneous incident as I was walking down the street. This time I went straight to the pulmologist who had seen me at the hospital, and he said “it’s a long shot, but let us test for Aspergillus”. It turned out to be positive, and the diagnosis “Aspergilloma” was derived. Aspergillus Fumigatus, it was. The fungus ball was sitting in the small cavity I had in the upper right lobe. Such cavities usually come from infections like TB, which I had never had. But all the messing with my thorax and my right lung in 1974 must have left the cavity there.

I was 65 then and had been considering retirement or semi retirement for some time. My wife and I then took the decision; I left my job in California and we went back to our native Denmark, from where I continued working as a consultant and advisor , on drastically reduced hours, but travelling internationally. I signed up as an outpatient at the pulmonary infection department at a large hospital in Hillerød, north of Copenhagen. I was put on a long term mix of antibiotics and itraconazole, and a year later, in spring 2006, it really looked as if I had got rid of the infection. I was taken off medication. But late in 2006, I started coughing up red sputum and was put on a daily long term dose of itraconazole. In March 2007, I had another incident of haemoptysis, and throughout the year I had two or three other incidents. In the autumn of 2007 I travelled to Manchester, England, to consult professor Denning. He would, he said, normally have suggested surgical removal of the aspergilloma, but due to scarring from my messy lung surgery many years ago, it was not advisable. So instead, he recommended embolization if the haemoptysis’ got worse.

Indeed, an operation had been discussed during my consultations at the Hillerød hospital, but the idea was abandoned due to the presumed high risk.

The itraconazole “maintenance treatment” continued into 2008, but in the late summer the frequency of haemoptysis increased. In August, for example, I had them almost every night.

3. Considering operation
At this time I decided to consult a well known thorax surgeon at the university Hospital in Odense, Denmark. The purpose of this was to get a better understanding on my part about how he would carry out such a procedure, if he should do it. He had prepared himself well and explained how he would suggest a “keyhole” operation, performed by himself and a

colleague, to remove the entire lobe in which the aspergilloma was sitting. He even showed me a video recording of a similar removal of a lobe with a cancer tumor (with his patient’s permission).

Back in Hillerød I told the pulmologist I had been seeing for a long time, about my visit to Odense. We concluded that, in spite of the risk, it was best to have this operation done, as the long term prognosis looked a bit sinister. So, on my request, he referred me to the hospital in Odense.

4. Operation
In November 2008 I was admitted to the hospital in Odense. The operation took five hours, and the old problem with my blood being slow to coagulate arose. Special drugs, now available, were used to stop the bleeding, and eventually my waiting family was told that the operation had been successful. Meaning, that the lobe with the aspergilloma had been removed in whole and without any damage. I did, however, develop a serious bleeding stomach (duodenum) ulcer due to stress from the surgery, and lost a considerable amount of blood that way – which had to be replaced.

The cavity, it appeared, had developed a hard, almost bony, wall, but fungal filaments had actually penetrated it. These filaments were found to be dead, however, probably due to the Itraconazole maintenance doses; but I was later informed that this had been “the eleventh hour”, i.e. the infection could have turned invasive if I had waited any longer.

5. Post Operation
It is a normal procedure to have several hoses draining the thorax cavity over the first few days after the operation. Samples were taken from the drains, and no Aspergillus was found. However, blood tests taken a month later, in January, showed Aspergillus antibodies. A CT scan revealed nothing unexpected. But blood samples did indeed suggest that the fungus was still there, a rather disappointing conclusion.

However, a later CT scan and blood tests, in March 2009, showed that – apart from the missing lope – everything was normal, and the level of Aspergillus antibodies had almost shrunk to zero. The doctor’s opinion is that the first analysis showed a reaction to Aspergillus which would be found after many big surgeries – though normally not checked for. And that there is no fungus left in the Thorax after the removal of the lope.

Peter, April 22nd 2009

Post Scriptum November 23rd 2011

It has now been three years since the surgery. Over the first two years I had quarterly blood tests, xrays and consultations at Hillerød Hospital. This frequency is now down to twice a year. The last tests revealed no antibodies at all, and I am leading a normal life with no restrictions. I haven’t smoked since I was 25, but I eat normally and varied, and I drink alcohol regularly,

mostly wine with food. I lost weight during and after the operation, but it is now back to normal for my height . At 72 now, I continue to engage in several physical outdoor activities , and also travel quite often; mostly for pleasure, but at times for business.

As time passes I grow more and more confident that I am free of the infection – and…consider myself lucky that I made the right choice. I owe thanks to the surgeon and doctors I have seen during this “ordeal”. Apart from being professionally competent, they also demonstrated a readiness to discuss all the details and various options with me, enabling me to understand my situation and make the decision. I am also tremendously thankful to my wife Gudrun, who supported me throughout, without a moment’s hesitation.

Peter