Beware of the Devastating Pulmonary Aspergillosis Syndromes in Certain Environments

Sir,

Nowadays with more stem cell transplants and immunosuppressive therapies there has been a rise in pulmonary aspergillosis syndromes. The following illustrates such a case. A 49 year old man had a past history of ankylosing spondylitis with a bilateral hip replacement. He was also on surveillance for a superficial bladder tumour since 2007. His chest x-ray in 2008 was normal. In 2010 his CXR showed patchy opacification in the right apex. CT thorax confirm fibrotic changes. His bronchoscopy with BAL of the upper lobes and quantiferon all came back normal. The rheumatologist stepped up his treatment in 2011 by starting him on Etanercept. Follow-up CXR in 2012 revealed new cavities in both upper lobes. CT thorax confirmed the presence of aspergilloma within these cavities.
Recently, he was referred to the ED with a 1 month history of hemoptysis, pleuritic chest pain and night sweats. He is an ex smoker, lives with his wife and is fully independent. Vitals on admission were normal and there was biapical crackles on auscultation of the chest. His Hb was 8.6, WCC 18.7, neutrophils 14.6, platelets 826. Being on long term NSAID, he had a chronic renal impairment with an eGFR of 46 that was being followed up by the nephrologist. His CRP was 166. CXR showed worsening of biapical consolidation with the presence of new cavities with fluid levels that was confirmed on CT. Bronchoscopy and lavage of his right upper lobe again back normal for routine microbiology, fungal screen, TB and cytology. After being discussed at our radiology meeting, a CT FNA of the right apical cavity was performed which identifies abundant fungal hyphae. He was started on voriconazole and improved clinically with his inflammatory markers coming back to normal in the following few weeks.

Pulmonary aspergillosis syndromes include chronic pulmonary aspergillosis, invasive aspergillosis and allergic aspergillosis. Invasive aspergillosis is now recognised in patients with critical illness without neutropenia and in those with a mild degree of immunosuppresion including the use of steroid in COPD setting. Chronic pulmonary aspergillosis include simple aspergilloma which can be complicated by life-threatening hemoptysis and progressive destructive cavitary disease requiring antifungal therapy as in our case. Allergic bronchopulmonary aspergillosis occurs mostly in patients with asthma and cystic fibrosis. Reflecting on our case, chronic cavitary aspergillosis occurs mostly in patients with pre-existing lung disease and outcome are generally poor particularly without antifungal treatment.1

M Kooblall, E Moloney, SJ Lane

Respiratory Department Tallaght Hospital Dublin 24

Email: mineshamnch@gmail.com

References

  1. Patterson KC, Strek ME. Diagnosis and treatment of Pulmonary Aspergillosis Syndromes. Chest. 2014 Nov;146:1358-68.

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