SESSION TITLE: Infectious Disease Cases IV
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM
INTRODUCTION: Aspergillus tracheobronchitis (AT) is an uncommon form of invasive pulmonary aspergillosis. AT in immunocompetent patients is rare. We present a case of AT causing total lung collapse in an immunocompetent patient, who had significant improvement after bronchoscopic intervention and antifungal therapy.
CASE PRESENTATION: A 64-year-old woman with post tuberculosis bronchiectasis but without recent infection was admitted with exertional dyspnea, productive cough and subjective fever for three weeks. Examination revealed a thin woman with conversational dyspnea. Room air oxygen saturation was 96%. Breath sounds were absent on the entire left hemithorax. Chest radiography showed complete left lung collapse with tracheal deviation to the left and biapical scarring.(Figure 1) Empiric antibiotics were started without improvement. HIV test was negative. Flexible bronchoscopy revealed mucosal hyperemia and thick adherent yellowish-green mucus plugs obstructing the left mainstem bronchus. Only partial removal of the plugs was possible. The patient then underwent rigid bronchoscopy with additional removal of mucus plugs, but without improvement in atelectasis. Fungal stains of bronchoalveolar lavage fluid revealed septate hyphae, and later grew Aspergillus fumigatus. Bronchial brushings also revealed septate hyphae. Patient was started on voriconazole, and after two weeks of treatment, significant radiological and clinical improvement was demonstrated.(Figure 2)
DISCUSSION: In Aspergillus tracheobronchitis, the Aspergillus infection is entirely or predominantly limited to the tracheobronchial tree. Immunocompromised status is a major predisposing factor. Structural abnormalities of the airway may lead to development of AT in the absence of immunosuppression.(1) We believe post-tuberculous bronchiectasis might have played a role in the development of AT in our patient. Chest imaging is normal in nearly half of the patients at presentation and only about 8% present with atelectasis. To our knowledge, this is the first reported case of total lung collapse in an immunocompetent patient with AT in the English language literature. Therapeutic role of bronchoscopic interventions is not clear, and response to treatment is generally poor in immunocompromised patients. Our patient, after flexible and rigid bronchoscopy, and treatment with antifungal therapy improved significantly. Along with antifungal therapy, partial removal of the endobronchial obstruction through bronchoscopy may have played a role in early improvement in this patient.
CONCLUSIONS: Clinicians should be aware about this unique presentation of AT in an immunocompetent patient with bronchiectasis. Combined treatment modalities with bronchoscopic interventions and antifungal therapy should be considered in selected patients.
Reference #1: Clarke A, Skelton J, Fraser RS. Fungal tracheobronchitis. Report of 9 cases and review of the literature. Medicine (Baltimore). 1991;70(1):1-14.
DISCLOSURE: The following authors have nothing to disclose: Alpeshkumar Bavishi, Andrew Berman
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