Disorders of the Mediastinum: Pleura and Chest Wall |

Empyema Thoracis: A Rare Complication of Allergic Bronchopulmonary Aspergillosis FREE TO VIEW

Atulya Atreja, DM; Puneet Perhar, MD
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MMIMSR, Karnal, India

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A223. doi:10.1016/j.chest.2016.02.231
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SESSION TITLE: Pleura and Chest Wall

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Aspergillus species is one of the most common causes of fungal infection of the lungs.1 Three distinctive pattern of Aspergillus related lung diseases are recognized: saprophytic infestation of airways eg. Aspergilloma; allergic manifestations such as extrinsic allergic alveolitis, ABPA and tissue invasive disease called invasive aspergillosis.2 The Aspergillus empyema is a rare clinical entity and not included in classification of Aspergillus related lung disease.

CASE PRESENTATION: A 29 year old female, with history of prior treatment for pulmonary tuberculosis and bronchial asthma, presented with fever, dry cough and right sided chest pain for 15 days duration. On evaluation the chest radiograph showed left upper zone non homogenous consolidation with right pleural effusion. On thoracocentesis, thick fluid was drained. The fluid was exudative and cultures for bacterial or mycobacterial etiology were sterile. Fungal cultures of the fluid were inconclusive. Serum Immunoglobulin E was 21,943 kUA/L. When initial management with empirical antibiotics showed no response, patient was started on Voriconazole and Prednisolone. Thoracoscopic evaluation was planned but patient started to clinically improve and radiological resolution started after 10 days.

DISCUSSION: The involvement of pleura in ABPA is uncommon. Karan Madan et al reviewed literature to find seven cases of pleural effusion in ABPA. Five cases responded to steroid ± anti fungal therapy and one showed spontaneous resolution3 Rarely ABPA may present with paratracheal and hilar adenopathy, obstructive lung collapse, pneumothorax and bronchopleural fistula. The treatment consists of steroids along with antifungal agents and effective drainage of pus. Intensive inflammatory response, with release of cytokines and fungal translocation into the pleural space, leads to a local Th2-dependent inflammatory response or lung collapse, leading to “ex vacuo” pleural effusion.3

CONCLUSIONS: Tubercular Empyemas are a common presentation in Indian setting but empyema of fungal origin are rare. Glucocorticoid therapy for asthma and ABPA are often a predisposing factor for growth of mycobacterium. A diagnosis of TB needs to be definitely excluded, ideally by performing thoracoscopy. Hence a high index of suspicion is required to ensure timely diagnosis and treatment of this potentially lethal condition. Aspergillus is a rare cause of pleural effusion and must be thoroughly evaluated in patients with a history of asthma/ABPA.

Reference #1: Fraser DW, Ward JI, Ajello L et al. Aspergillosis and other systemic mycoses the Growing Problem. JAMA 1979;242:1631-5.

Reference #2: Seaton A. Actinomycotic and fungal diseases. In: Seaton A, Seaton D, Leitch AG, editors. Crofton and Douglas’s respiratory diseases. 5th ed. Oxford: Blackwell science ltd; 2000. p. 573-674

Reference #3: Karan Madan, Amanjit Bal, and Ritesh Agarwal. Pleural Effusion in a Patient With Allergic Bronchopulmonary Aspergillosis. Respir Care 2012;57(9):1509-1513.

DISCLOSURE: The following authors have nothing to disclose: Atulya Atreja, Puneet Perhar

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