Late pleuropulmonary aspergillosis after the treatment of pneumothorax: Report of three cases

A bullectomy for spontaneous pneumothorax is often combined with pleurodesis to prevent recurrence. A recurrent or progressive residual bullous lung beneath adhesive pleura neovascularized from the chest wall may be affected by aspergillosis. Of the 12 patients with pulmonary aspergillosis secondary to bullous lung disease treated surgically at our hospital since 1974, 3 underwent a bullectomy with pleurodesis for spontaneous pneumothorax. The presenting symptoms in all cases were hemosputum. Aspergillus lesions affected the patients in the right upper lobe, the left apical segment, and both apical segments at 16, 9, and 13 years, respectively, after a bullectomy. Angiograms demonstrated hypervascularization in the intercostal and internal thoracic arteries, as well as in the bronchial branches. Catheter embolization for airway bleeding was not effective in 1 patient. Four operations, including an emergency procedure for massive intrapulmonary bleeding, were performed. These included a right upper lobectomy followed by a left upper segmentectomy at second-look operation in 1 patient who required bilateral chest wall resections. All patients survived the operations. Intraoperative bleeding ranged between 700 and 3500 ml (1543 ml on average), and bleeding foci were mainly from the chest wall, with hypervascularization stemming from the ipsilateral chest wall. Postoperative complications included pleural space hemorrhaging and a bronchopleural fistula, both of which required additional chest wall resections. Patients with bullous lung disease late after a bullectomy with pleurodesis may thus be associated with complex pleuropulmonary aspergillosis, which requires surgical therapy concomitant with a chest wall resection.