Pulmonary aspergilloma diagnosed in patient with a 1-week history of small volume hemoptysis
A 51-year-old man from the Democratic Republic of the Congo arrived at the hospital with a one-week history of small-volume hemoptysis. A computed tomography (CT) of the chest sixteen months prior to presentation revealed a right upper lung cavitation. The cavitation was caused by treated pulmonary tuberculosis (Panel A). Physical examination revealed diminished breath sounds at the apex of the right lung in the current case. A repeat chest CT revealed thickening of the right upper lung cavitation wall and a new intracavitary mass (Panel B). Aspergillus-specific IgG antibodies were detected in a serum sample, but not human immunodeficiency virus antibodies. A pulmonary aspergilloma diagnosis was made.
Sputum samples were collected to identify the fungus species, test for antifungal susceptibility, and rule out concomitant tuberculosis. Microscopy revealed septate hyphae branching at acute angles (Panel C, no stain; and Panel D, fluorescent stain). A sputum culture supported the growth of a smoky-gray fungal colony (Panel E) with uniseriate conidiophores (Panel F). Additionally, mass spectrometry was used to identify Aspergillus fumigatus. Voriconazole treatment was started. Before a lobectomy could be planned, the patient was lost to follow-up. He presented with significant hemoptysis 14 months later and underwent pulmonary-artery embolisation.
Pulmonary aspergilloma normally affects immunocompromised people but can also affect those with COPD
Invasive pulmonary aspergillosis (IPA) is a severe disease that can affect not just highly immunocompromised people. It also affects critically ill patients, Moreover, those suffering from chronic obstructive pulmonary disease (COPD). Chronic necrotising aspergillosis (CNA) is a locally invasive infection that primarily affects patients with modest immunodeficiency or chronic lung illness. Noninvasive types of Aspergillus lung illness include aspergilloma and allergic bronchopulmonary aspergillosis (ABPA). Aspergilloma is a fungus ball that grows in an already existing hollow within the lung parenchyma, whereas ABPA is a hypersensitivity manifestation in the lungs that nearly usually affects people with asthma or cystic fibrosis.
The first case of IPA was described in 1953. Its prevalence has increased over the last two decades as a result of the extensive use of chemotherapy and immunosuppressive medications. Groll et al. found that the rate of invasive mycoses increased from 0.4% to 3.1% of all autopsy done between 1978 and 1992. Over the course of the trial, IPA climbed from 17% to 60% of all mycoses diagnosed on autopsy. IPA mortality increases 50% in neutropenic patients and reaches 90% in recipients of haematopoietic stem-cell transplantation (HSCT).
Risk factors
The first line of defence against inhaled Aspergillus conidia is alveolar macrophages. Pathogen recognition receptors, such as Toll-like receptors, Dectin-1, and mannose-binding lectin, recognise specific fungal wall components in the lungs and generate cytokines that drive neutrophil recruitment, the primary defence mechanism against Aspergillus hyphae. Immunodeficiency is the most common risk factor for IPA, and it includes neutropenia, HSCT and solid-organ transplantation, extended therapy with high-dose corticosteroids, haematological malignancy, cytotoxic therapy, severe AIDS, and chronic granulomatous disease (CGD).
Clinical presentation
In most situations, Aspergillus enters the lower respiratory system through inhalation of infected spores. Other than the lungs, IPA can begin in the sinuses, the gastrointestinal system, or the skin (through intravenous catheters, prolonged skin contact with adhesive tapes, or burns).
Symptoms are nonspecific and sometimes mistaken for bronchopneumonia: fever that does not respond to treatments, cough, sputum production, and dyspnea. Patients may also experience pleuritic chest pain (due to vascular invasion resulting in thromboses that create minor pulmonary infarcts) and mild to severe haemoptysis. IPA is one of the most common causes of haemoptysis in neutropenic individuals, and it may be related to neutrophil recovery cavitation.
Aspergillus infection can potentially spread haemolytically to other organs, including the brain. Seizures, ring-enhancing lesions, cerebral infarctions, intracranial haemorrhage, meningitis, and epidural abscesses are all possible outcomes. Other organs that may be implicated include the skin, kidneys, pleura, heart, oesophagus, and liver.
Source: NEJM
