Aspergillus can cause a wide spectrum of disease, from an indolent aspergilloma to fulminant invasive aspergillosis. We report here a rare case of Pancoast’s syndrome caused by chronic necrotizing aspergillosis (CNA).
A 57- year old lady presented with right upper chest wall pain and intermittent blood-streaked sputum. Her past history was remarkable for right upper lobe bronchiectasis, a right mastectomy for breast cancer five years previously (with no known recurrence of disease), as well as a right neck of femur fracture that was complicated by prothesis infection and required several revisions.Chest radiographs (CXR) initially showed chronic collapse/ consolidation of the right upper lobe. Bronchoscopy showed no endobronchial lesions and mycobacterial cultures were negative. Over the next six months, the patient developed a right ptosis with weakness and wasting of the T1 distribution of muscles. Serial CXRs and Computerised Tomography (CT) of the thorax showed replacement of the right upper lobe by thickened pleura and necrotic debris with a progressively enlarging mycetoma within. Transthoracic needle aspiration of the pleura and of the soft tissue mass yielded Aspergillus fumigatus from both histology and cultures. She was started on oral itraconazole, but developed severe nausea and diarrhea. Two weeks after starting therapy, she developed signs of superior venal caval obstruction (SVCO) as well. CT thorax confirmed this and also showed invasion of the right internal jugular vein. She was admitted for a course of intravenous amphotericin. However, 13 days after starting treatment, she deteriorated suddenly with clinical evidence of pulmonary embolism and succumbed.DISCUSSION: CNA is characterised by an indolent, progressive local invasion of lung tissue and usually occurs in patients such as ours, who have evidence of pre-existing lung disease and are marginally immunocompromised eg by poor nutrition or chronic illness.1 CNA is traditionally differentiated from invasive aspergillosis by a more indolent course and by lack of vascular invasion. The clinical course of this patient falls somewhat in between - she had a rather indolent course of progression, but with macrovascular invasion and progressive parenchymal destruction. Aspergillus infection should perhaps be considered more of a spectrum, from aspergilloma to CNA to invasive aspergillosis, rather than as separate clinical entities.Treatment with intravenous amphotericin or itraconazole syrup has been reported to be useful.12 Reported morality rates for CNA vary from 25 – 60% and may be related to the time from presentation to diagnosis; a high index of suspicion and early treatment may improve outcome.1Pancoast’s syndrome is caused by involvement of the eighth cervical and first two thoracic nerve roots by compression or invasion of a lesion at the superior thoracic inlet. It is most commonly caused by malignancy. Pancoast’s syndrome caused by aspergillus is rare. There are at least two previous reports in the literature,34 but both of these patients were frankly immunocompromised and had invasive aspergillosis. To our knowledge, this is the first report of Pancoast’s Syndrome caused by chronic necrotizing pulmonary aspergillosis.
In a marginally immunocompromised host, aspergillus infection can be slowly yet relentlessly invasive and should be treated with respect. Vascular invasion and invasion of the superior sulcus can occur in chronic necrotising aspergillosis, resulting clinically in Pancoast’s syndrome.
T. Ong, None.