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 ::  Abstract
 ::  Introduction
 ::  Material And Methods
 ::  Case Reports
 ::  Results
 ::  Discussion
 ::  References
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Year : 1979  |  Volume : 25  |  Issue : 1  |  Page : 57-60

Pulmonary infections by the fungus aspergillus

Departments of Microbiology and Medicine, Kasturba. Medical College, Manipal 576 119, Karnataka, India

Correspondence Address:
P V Rao
Departments of Microbiology and Medicine, Kasturba. Medical College, Manipal 576 119, Karnataka
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Source of Support: None, Conflict of Interest: None

PMID: 379325

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 :: Abstract 

Five cases of respiratory infection by Aspergillus fumigates are described. Species of aspergillus is ubiquitous in nature. Therefore, repeated demonstration of fungus, serological evidence tend radiological findings are essential for diagnosis. Potassium iodide is a useful drug in aspergillus infection of the lung when other drugs are not available. Injection Emetine hydrochloride is promising as a therapeutic agent in pulmonary aspergillosis, where the lung parenchyma is involved.

How to cite this article:
Rao P V, Shivananda P G, Vikineshwari S, Vasavi G, Rao K. Pulmonary infections by the fungus aspergillus. J Postgrad Med 1979;25:57-60

How to cite this URL:
Rao P V, Shivananda P G, Vikineshwari S, Vasavi G, Rao K. Pulmonary infections by the fungus aspergillus. J Postgrad Med [serial online] 1979 [cited 2023 Jun 8];25:57-60. Available from:

 :: Introduction Top

Recently, Aspergillus as a secondary invader is being recognised with increas­ing frequency. Out of about :350,species [13], described, only a few are considered as pathogenic to man notably Aspergillus fumigatus. [12]

We describe below four cases of pul­monary aspergillosis and one case of pulmonary aspergilloma diagnosed in the Kasturba Medical College Hospital, Manipal, during June 1974 to June 1977.

 :: Material And Methods Top

Cases clinically and radiologically diag­nosed as pulmonary tuberculosis, but had failed to respond to antitubercular treat­ment were re-examined or reviewed. In five such cases fungal elements could be demonstrated and cultured. Sputum specimens were collected with strict asceptic precautions as far as possible.

Soon after waking, the patient was ask­ed to rinse his mouth thrice with sterile saline and all the coughed up expectorate was collected directly into a sterile wide mouthed container. This was repeated on three consequtive days. Bronchial aspiration materials were collected in a sterile container.

The sputum and bronchial aspiration materials were processed soon after the collection. The sputum was transferred to a sterile petri-dish. Purulent portion of sputum was selected for wet smear preparation with 20% KOH. [4] Smears were also made and stained by Gram's and Ziehl Neelsen's methods. The material was cultured on Blood agar, Lowenstein Jensen, Robertson's Cooked Meat Medium and Sabourauds Glucose Agar in duplicate. (One tube was in­cubated at 37°C and the other at 25'C). Sputum was also examined for the pre­sence of malignant cells.

The patients' sera were put up for gel precipitation tests by Ouchterlony techni­que and the antigen for gel diffusion was prepared according to the method described by Longbottom et al [9] except that the final concentrated dialysate was not lyophilised.

 :: Case Reports Top

Case 1: A 32 year old male farmer suffered from cough with expectoration for the last six months and did not give any history of hae­moptysis. His hemoglobin was 12 grams% . The systemic examination revealed only crepitations which were heard over both the lung fields. Blood examination showed eosinophil count of 17% and ESR was 12 mm 1st hour (Wester­gren). The radiograph showed diffuse mottling in both the lung fields (See [Figure 1] on page 56B). This patient expired after 6 months. Con­ant's rapid regimen of Potassium iodide treat­ment did not help him.

Case 2: A 41 year old male patient sought our advice for the complaints of haemoptysis and cough of last two months' duration. The patient was anaemic (Hemoglobin 10 grams) and clubbing of the fingers were present. He said he had suffered from pulmonary tuber­culosis about 10 years back. The systemic exa­mination did not reveal anything except that coarse crepitations were heard over the left supra and intrascapular regions. The blood exa­mination showed eosinophil count of 29% and ESR was 10 mm 1st hour (Westergren). The X-ray picture showed a large cavity in the left upper lobe completely filled with a "fungal ball" separated by a clear margin. No fluid level was observed, (See [Figure 2] on page 56B). This patient reponded well to our saturated solu­tion of potassium iodide (See [Figure 3] on page 56B).

Case 3: A 35 year old farmer suffering from infective hepatitis for the last 15 days was ad­mitted for this complaint. He also gave a history of suffering from cough with expectoration for the last six months. The systemic examination did not reveal any abnormalities. His eosino­phil count was 16% and ESR was 12 mm 1st hour (Westergren). The radiograph showed a homogenous opacity in the right mid zone. As this lesion was diffuse and not demarkated, it was considered to be a diffuse or paranchymat­ous type. Histopathological evidence confirmed that the hepatitis was of viral etiology. He also responded well to Conant's regimen.

Case 4: A 40 year old house-wife came with complaints of cough with expectoration and breathlessness of 4 months' duration. Associat­ed with this she had pain in the chest and haemoptysis for the last 2 months. The sputum was whitish and non-foul smelling, Systemic examination did not give any positive findings. The blood examination showed eosinophils of 20% and ESR 16 mm 1st hour (Westergren). The chest radiograph showed homogenous opacity in the right mid zone, a lesion similar to the one described above. This patient also responded well to the potassium iodide treat­ment.

Case 5: A 28 year old male was admitted to the hospital for the complaints of cough with expectoration and haemoptysis of 6 months' duration. The chest X-ray showed diffuse mott­ling in both the lung fields and was originally suspected to be a case of miliary tuberculosis. The blood examination showed 21% eosinophils and ESR was 10mm 1st hour (Westergren). This patient was treated with injection Emetine hydrochloride 60 mg per day for a period of 10 days [5] and the response has been very pro­mising and dramatic.

 :: Results Top

In all our cases, wet mount preparation and direct smear were positive for hyphal fragments and characteristic fungal spores were seen in many. All sputum samples were negative for acid fast bacilli by direct smear, by concentra­tion method (Petroff's) and by culture. They were negative for malignant cells. No anaerobic organisms were isolated in Robertson's Cooked Meat Medium and Thioglycollate medium. In all the patients, Aspergillus fumigatus was iso­lated and identified according to Conant et al. [3] Sera from all five patients gave precipitation lines with Aspergillus fumi­ gatus antigen only.

The other organisms grown were Staphylococcus coagulase negative in 3 cases and Beta-haemolytic streptococci in the other two. These were grown on blood agar plate alongwith Aspergillus.

 :: Discussion Top

The spores of the Aspergillus species are widely distributed in nature and are frequently found in the soil and the vegetable matter. Aspergillus fumigatus and Aspergillus niger are able to grow in or in close association with human tissue, the respiratory tract being the most fre­quent point of contact. [6] In the review article by the British Tuberculosis As­sociation, a review of 544 cases of healed pulmonary tuberculosis with residual cavities showed 171; aspergilloma and 3% probable aspergilloma in about 3-4 years of follow up. [1] However only one case cited by us gave a definite history of pulmonary tuberculosis.

It is well documented that the sapro­phytic fungus may be changed into an opportunistic pathogenic form by the in­discriminate use of antibiotics and im­munosuppressive agents. [11] In all our cases they had received several antibiotics and corticosteroids at the local hospital.

The Aspergillus infections of the lung are regarded by many as an occupational hazard particularly with those agricul­turists who are working with hay, grain and flour. [2],[3],[4] In our cases, four of them were farmers. Experimentally animals have been infected following the inhala­tion of spores with subsequent germina­tion and proliferation in the lung tissues. [10]

Aspergillosis is a most troublesome laboratory contaminant. Being ubiquit­ous, one has to be very careful to in­criminate this fungus as an aetiological agent. However, we are of the opinion that the presence of Aspergillus in the clinical material perticularly sputum, should not be ignored as a contaminant and the case must be investigated in full detail. The diagnosis of pulmonary as­pergillosis and aspergilloma depends up-­on the clinical symptoms, radiological findings and the repeated demonstration and isolation of the fungus in the sputum. [3] The growth of the fungus from the bron­chial aspiration material [12] and demons­tration of precipitin in the patient's serum are of value in the diagnosis of Aspergillus infection [9] and could be the conclusive evidence. [14]

Therapy still remains a problem. Iodides, nystatin and amphotericin-B, have been tried with uncertain results. [7] For want of sophisticated drugs we re­sorted to Conant's regimen. [7] Three cases improved both radiologically and clinically and the sputum examination did not reveal any fungus after treatment. These patients are being followed up. One patient who was a well advanced case did not respond to potassium iodide treatment and died after 6 months. No postmortem was allowed by the relatives.

Injection Emetine hydrochloride has been tried in pulmonary aspergillosis and the reports were favourable. [8] We also tried this in one case of pulmonary aspergillosis and the response to this treatment has been promising. The haemoptysis which was continuous and a major feature had subsided and the patient's general condition was consider­ ably improved both clinically and radio­ logically

 :: References Top

1.British Tuberculosis Association, London: Report of the Research Subcommittee: Tubercle, 49: 1, 1968; as quoted in Lancet,1: 637, 1977.  Back to cited text no. 1    
2.Coe, G. C.: Primary bronchopulmonary aspergillosis-an occupational disease. Ann. Intern, Med., 23: 423-425, 1945.  Back to cited text no. 2    
3.Conant, N. F., Smith, D. T., Baker, R. D. and Callaway, J. L.: "Manual of Clinical Myocology," 3rd Edition W. B. Saunders Company, Philadelphia, 1971. pp. 377-402.  Back to cited text no. 3    
4.Cruickshank, R., Duguid, J. P. and Swain. R. H. A.: "Medical Microbiology." E.S. Livingstone Ltd., London, 1965. p. 514.  Back to cited text no. 4    
5.Davidson, S. and MacLeod, J.: "The Principles and Practice of Medicine." 4th Edition. The English Language Book Society (ELBS) Publication, 1972, p. 425.  Back to cited text no. 5    
6.Edje, J. R., Stansfield, D. and Fletcher, D. E.: Pulmonary aspergillosis in an un­selected hospital population. Chest, 59: 407-413, 1971.  Back to cited text no. 6    
7.Foushee, J. W. S. and Norris, F. G.: Pulmonary aspergillosis. J. Thorac. Surg., 35: 542-548, 1958.  Back to cited text no. 7    
8.Jesiotr, M.: Treatment of aspergillosis with emetine hydrochloride, Scand. J. Resp. Diseases, 54: 326, 1.973. Quoted by Eastridge, C.E.. In, The Editorial of Ann. Thorac. Surg., 22: 102-103, 1976.  Back to cited text no. 8    
9.Longbottom, J. L. and Peyp's, J.: Pulmo­nary aspergillosis: diagnostic and immu­nological significance of antigens and `C' substance in Aspergillus fumigates. J. Path. and Bact., 88: 141-151, 1964.  Back to cited text no. 9    
10.McPherson, P.: Pulmonary aspergillosis in Argyll. Brit. J. Dis. Chest., 59: 148­157, 1965.  Back to cited text no. 10    
11.Pecora, D. V. and Toll, M. W.: Pulmo­nary resections for localized aspergillosis. New Eng. J. Med., 2i3: 785-787, 1960.  Back to cited text no. 11    
12.Saliba, A.. Pacini, L. and Beatty, 0. A.: Intracavitary fungus balls in pulmonary aspergillosis. Brit. J. Dis. Chest., 55: 65­71, 1961.  Back to cited text no. 12    
13.Simons, R. D. G. PH.: "Medical Myco­logy." Elsevier Publishing Co., London, Amsterdam, Houston, & New York. 1954, p. 384.  Back to cited text no. 13    
14.Warnock, D. W.: Detection of Aspergillus fumigatus precipitins: a comparison of counter-immuno electrophoresis and dou­ble diffusion. J. Clin. Path., 30: 388-389, 1977  Back to cited text no. 14    


  [Figure 1], [Figure 2], [Figure 3]


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