UNCOMMON PRESENTATION OF PULMONARY ASPERGILLOMA

Unusual case of chronic cavitary pulmonary aspergillosis presenting as spontaneous pneumothorax in an immunocompromised man

Chronic cavitary pulmonary aspergillosis (CCPA) is a slow destructive type of chronic pulmonary aspergillosis, characterised by multiple pulmonary cavities that develop and expand over several months or years. Pleural involvement in the form of pneumothorax has been rarely reported in CCPA. We report such an unusual case of an immunocompromised male, with a history of chronic cough and fever, presenting with acute onset of shortness of breath. Chest imaging showed bilateral multiple cavitating nodules, ground glass opacities and dense right middle lobe consolidations and right-sided pneumothorax. Bronchoalveolar lavage (BAL) showed septate hyaline hyphae on KOH (potassium hydroxide) staining and fungal culture grew Aspergillus fumigatus BAL and serum galactomanan were positive and serum IgG for A. fumigatus was 58 MgA/L (0-40MgA/L) confirming the cause of spontaneous secondary pneumothorax in our patient as CCPA.

Spontaneous pneumomediastinum: Experience in 13 adult patients

BACKGROUND

Spontaneous pneumomediastinum is an uncommon disorder. There is a lack of information on spontaneous pneumomediastinum in India. We aimed to understand the clinical profile, hospital course, and long-term outcome of such patients.

METHODS

We retrospectively reviewed all patients (aged ≥15 years) diagnosed with spontaneous pneumomediastinum in the respiratory ward of a tertiary care hospital over a 7-year period from 2005.

RESULTS

Of the 3326 patients hospitalized during the study period, 13 (10 male) were diagnosed with spontaneous pneumomediastinum, constituting 0.39% of all hospitalizations. The median age was 37 years (interquartile range 20-55 years). The most common presenting symptom was dyspnea in 85% followed by neck swelling (69%), chest pain (69%) and cough (54%). Subcutaneous emphysema and preexisting lung diseases were identified in 11 (85%) patients each. Post-tubercular pulmonary sequelae (5 patients) and asthma (4 patients) were the most common underlying lung diseases. Pneumothorax was identified in 6 (46%) patients; 4 required tube thoracostomy. Chest radiography was diagnostic in 92% of patients. The median length of hospital stay was 9 days (interquartile range 6-12 days). No recurrence was reported in 11 patients followed up for a median of 1550 days (interquartile range 691-1909 days).

CONCLUSIONS

Spontaneous pneumomediastinum is a benign disorder, but underlying lung diseases and concomitant pneumothorax are likely to complicate the disease course. Exacerbation of post-tubercular obstructive airway disease is a common risk factor for spontaneous pneumomediastinum in a tuberculosis endemic country.

Multifocal pulmonary aspergillomas: case series and review

Multifocal lung parenchymal cavities containing multiple aspergillomas are not well-recognized features of chronic pulmonary aspergillosis (CPA). We identified five patients with multiple cavities containing fungal balls from our accumulated cohort of ∼300 patients with CPA. Corticosteroid exposure and radiological and serological characteristics were assessed. The patients, aged 19-55 years, developed 3-11 cavities (or nodules in one case) with thin walls, usually within the lung parenchyma, with very limited pleural involvement. Four had asthma (severe in three) and one had cystic fibrosis; three had allergic bronchopulmonary aspergillosis. All patients had received corticosteroids orally or by inhalation. Four patients had elevated Aspergillus IgG antibodies; one had elevated Aspergillus-specific IgE. Three patients developed azole resistance on antifungal therapy, after benefit, one of whom underwent a successful bilateral lung transplant, later complicated by a fatal mycotic cerebral aneurysm. Multiple aspergillomas is a new distinct manifestation of CPA. The lack of inflammatory response and the distribution of the cavities in the lungs are remarkable. Aspergillus nodules could evolve into cavities with aspergillomas. The management and development of azole resistance in these patients is problematic.

[Huge aspergilloma developed within a zone of scleroderma-related pulmonary fibrosis]

In pulmonary aspergilloma, Aspergillus colonizes and proliferates as a saprophyte in deterged cavities deprived of local defense. Although pulmonary tuberculosis constitutes the one well-know predisposing factor, other causes can create favorable conditions. We describe a first published case of a huge aspergilloma which developed within a zone of pulmonary fibrosis secondary to systemic scleroderma. The patient was a 58-year-old woman in poor general health who experienced repeated episodes of hemoptysis and dyspnea. Physical examination disclosed sclerodactyly, generalized cutaneous sclerosis and Raynaud's phenomenon. There was no clinical history of pulmonary tuberculosis or bronchectasis. Aspergillosis serology was positive. Broncho-alveolar liquid was positive for Aspergillus fumigatus at direct examination and after culture. Immunological assessment confirmed scleroderma. The chest computed tomography scan showed a huge oblong-shaped opacity in the upper left lobe which had developed within a zone of pulmonary fibrosis. Medical management was instituted. The clinical course was marked by repeating hemoptysis and the stability of pulmonary lesions after two years. Management of scleroderma-related pulmonary aspergiloma remains difficult and complicated. Prognosis depends on the course of both conditions, scleroderma and aspergillosis.