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Coexistence of Nontuberculous Myocbacteria and Aspergilloma in a 62-Year-Old Female Presenting With Recurrent Nonmassive Hemoptysis FREE TO VIEW

John Noel Chan, MD; Shirley Jane Panganiban, MD; Angelo Adraneda, MD; Jonathan Paolo Rustia, MD
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Chinese General Hospital & Medical Center, Manila, Philippines

Chest. 2014;145(3_MeetingAbstracts):93A. doi:10.1378/chest.1736505
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SESSION TITLE: Tuberculosis Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: In the Philippines, tuberculosis (TB, has been one of the most common causes of hemoptysis. This case report presents a patient with hemoptysis that may be a sequelae of chronic TB. However, further investigation reveals a concomitant non-tuberculous mycobacterial (NTM) infection and the co-existence of aspergilloma aggravating the condition.

CASE PRESENTATION: She is a 62-year-old female who was admitted due to recurrent hemoptysis. Her chest radiograph upon admission showed ill-defined bilateral upper lung infiltrates. She has had treatment for TB previously but was uncompliant in two occasions. Most recently, she has been in Category II of anti-tuberculosis therapy (ATT) returning after default. Mullti-drug resistance tuberculosis (MDRTB) has been ruled-out. A chest CT scan was done and showed findings consistent with TB and bronchiectasis but a 2.3cm cavitary lesion, not appreciated in chest radiograph, was seen in the right upper lobe (RUL). We have worked on an impression of a concomitant aspergilloma. With these findings, a bronchoscopy was done with findings showing blot clots on the RUL. Analysis of bronchial washings showed: Negative for malignant cells and fungal elements. Pending the results of the culture and considering a negative finding on fungal staining, she was re-started on ATT. A sputum specimen was sent for culture. In 6 weeks time, both culture from bronchial washings and sputum revealed NTM. It was negative for fungal growth. Therapy was then tailored for NTM. She has been asymptomatic while on treatment for NTM, but was readmitted on the 7th month of treatment with recurrent hemoptysis. A chest CT angiography was done to rule out a pulmonary vascular cause - and this was unremarkable for such. At this point we have come up with an impression of hemoptysis that may be due to three sources (1) TB broncheictasis, (2) NTM , and (3) a possible Aspergilloma. A surgical consult was sought and she has consented for operation. An intraoperative bronchoscopy was done and was able to localize the bleeding in the RUL. She underwent video-assisted thoracoscopy with RUL lobectomy. The tissue diagnosis was an Aspergilloma, non-invasive. She has been symptom free up to present.

DISCUSSION: The overlap of different disease conditions may aggravate a patient’s presenting symptom. The association of TB and Aspergilloma has been widely reported. In areas where it is endemic, TB is still the most common condition predisposing subjects to aspergilloma formation. In a study in 2004, it was further stated that there was an association between the presence of Aspergillus antibodies and hemoptysis in patients with bronchiectasis. The most recent report of the co-existence between a pulmonary aspergillus and TB was presented in the latest bulletin of the WHO in 2011. In the Philippines, the estimated chronic pulmonary aspergillosis 5-year prevalence was 51% and this is after being treated with a PTB infection. In a report by Hafeez, four cases of pulmonary mycobacterial disease was complicated by the development of chronic necrotising pulmonary Aspergillosis - making treatment difficult and worsened prognosis. In this case we have exhausted all efforts and means to diagnose the source of her hemoptysis. We were frustrated for such recurrence despite maximizing treatment. Nonetheless, she is doing better after surgery. However with underlying problems such as TB bronchiectasis and NTM infection, it will be uncertain if she remains well and it is probable that hemoptysis may recur.

CONCLUSIONS: The co-exsistence of NTM and Aspergilloma may complicate hemoptysis in a patient with an underlying chronic pulmonary insult. All efforts must be exhausted and diagnostic armaments be maximized in order to promptly address the needs of the patient.

Reference #1: Non-tuberculous mycobacterial lung infection complicated by chronic necrotising pulmonary aspergillosis. I Hafeez,M F Muers, S A Murphy,E G V Evans, R C Barton, P McWhinney. Thorax 2000;55:717-719

Reference #2: Coexistence of intracavitary fungal colonization (fungusball) and active tuberculosis. GISELA UNIS, PEDRO DORNELLES PICON(TE SBPT), LUIZ CARLOS SEVERO. J Bras Pneumol 2005; 31(2): 139-43.

Reference #3: Emerging of Mycotic Infection in Patients Infected with Mycobacterium tuberculosis. Sunita Bansod and Mahendra Rai. World Journal of Medical Sciences 3 (2): 74-80, 2008

DISCLOSURE: The following authors have nothing to disclose: John Noel Chan, Shirley Jane Panganiban, Angelo Adraneda, Jonathan Paolo Rustia

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