consideration objectives: Although pulmonary mycetoma has been well-described in immunocompetent innkeepers the only description in HIV-infected patients has been of 10 patients from our institution.

consideration objectives: Although pulmonary mycetoma has been well-described in immunocompetent innkeepers the only description in HIV-infected patients has been of 10 patients from our institution, from 1992 to 1995 To further investigate the impact of HIV status forward the presentation and course of pulmonary mycetoma, we guidanceed a follow-up study.

Design: Retrospective review of all cases of pulmonary mycetoma at Bellevue Hospital from 1992 to 1999

Setting: Patients were evaluated in succession the inpatient chest service and in the outpatient chest and HIV clinics of Bellevue Hospital in just discovered York City.

Patients: We identified 74 patients with pulmonary mycetoma; 20 of them were HIV-infected (27%)

Interventions: The 20 HIV-infected patients were treated with antiretroviral and/or antifungal therapy.

Measurements and results: Predisposing diseases were pulmonary tuberculosis (TB) Pneumocystis carinii pneumonia (PCP) or one as well as the other TB and PCP. Seventeen patients had a CD4+ confined apartment count of < 100 cells/[micro]L at presentation. Hemoptysis was ready in 13 patients, but was massive in solitary 1 patient. Cough was belonging to all Of the 18 patients for whom follow-up was available, 11 received antifungal treatment and 7 were observ without therapy. Six patients received one as well as the other antiretroviral and antifungal therapy. Disease progression occurr in 50% no other than five patients exhibited radiographic or clinical improvement. All five were treated with the two antiretroviral and antifungal therapy.

Conclusions: PCP is a risk factor for pulmonary mycetoma in the HIV-infected individual. HIV-infected patients with mycetomas have a significant rate of disease progression, although they rarely have life-threatening hemoptysis. A combination of antifungal and antiretroviral therapy may improve the clinical issue in HIV-infected patients with pulmonary mycetoma.

guide words: aspergilloma; Aspergillus fumigatus; HIV; mycetoma

Abbreviations: PCP = Pneumocystis carinii pneumonia; TB = tuberculosis

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A pulmonary mycetoma consists of a close ball of fungal filaments and amorphous material containing small rooms and fibrin which fill a preexisting pulmonary cavity. Aspergillus, a fungus quick in emergencies in soil water and decaying vegetation, is common of the more common fungi that can cause this condition and various other diseases in the human innkeeper In the lung, Aspergillus infection can cause obstructive bronchopulmonary aspergillosis, mucoid impaction of the airways, tracheobronchitis, ulcerative bronchitis, pseudomembranous tracheobronchitis, invasive aspergillosis, or aspergilloma. An aspergilloma is defined as Aspergillus infection of a preexisting pulmonary cavity without tissue invasion. Pulmonary mycetomas, and particularly aspergillomas, in the immunocompetent patient have been well-described in the literature, (1-6) however little has been published upon the presentation and clinical course of the disease in the HIV-infected patient.

In the immunocompetent population, mycetoma come to one's minds in 10 to 15% of patients with cavitating lung diseases. (78) These patients are frequently asymptomatic, but up to 25% may have massive hemoptysis. (3) The course of disease is variable, and patients are oftentimes observed without therapy unless they evolve hemoptysis. HIV infection may change the presentation and course of mycetoma in several important ways. HIV-infected patients are particularly susceptible to cavitary lung disease, including Pneumocystis carinii pneumonia (PCP) and tuberculosis (TB) as well as necrotizing bacterial pneumonias. Immunocompromised patients are susceptible to more invasive forms of fungal infection, with equal reason it is possible that colonization of a cavity in HIV-infected patients may predispose them to the increase of more invasive disease.

There have been several case reports of mycetomas in HIV-infected individuals, (9-13) on the contrary to our knowledge, the solitary case series of mycetomas in HIV-infected patients to date is a previous thought from our institution (14); in that reflection the clinical presentation, progression of disease, treatment, and consequence of pulmonary aspergilloma were compared in 10 HIV-infected patients and 15 HIV-negative patients. The major findings of that cogitation were the following: (1) although tuberculosis and sarcoidosis were the most numerous prevalent predisposing diseases, a history of PCP was a risk factor for pulmonary aspergilloma in the HIV-infected individual; (2) HIV-infected individuals with a CD4+ compute of < 100 cells/[micro]L were more likely to have disease progression despite treatment; and (3) HIV-infected patients were les likely than HIV-negative patients to have hemoptysis requiring intervention.

Since that subject of attention was completed, significant strides have been made in the treatment of HIV infection. With the advent of highly effective antiretroviral therapy, patients with HIV are living longer with improved immunologic profiles. In addition, the widespread use of PCP prophylaxis has greatly reduc the incidence of PCP To further investigate the impact of HIV status forward the presentation and course of pulmonary mycetoma in this changing environment and to diocese whether these patients are at risk, in the lengthy term, for the development of more invasive disease, we course of lifeed a follow-up study in which we reviewed the later clinical course of the original 10 patients and identified an additional 10 cases of pulmonary mycetoma in HIV-infected individuals.

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