Chest Infections: Fellow Case Report Poster - Chest Infections I |

Pseudomembranous Tracheobronchitis Due to Aspergillus FREE TO VIEW

Anirudh Aron, MD; Upasna Aron, MD
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University of Tennessee, Memphis, TN

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

Chest. 2016;150(4_S):118A. doi:10.1016/j.chest.2016.08.127
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SESSION TITLE: Fellow Case Report Poster - Chest Infections I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Aspergillus tracheobronchitis (ATB) is a form of invasive aspergillosis confined to the tracheobronchial tree rather than the parenchyma and occurs in patients who are immunocompromised or with structural lung diseases.

CASE PRESENTATION: A 38-year-old male presented with cough, hemoptysis, generalized weakness and dyspnea on minimal exertion. Five months previously he was diagnosed with combined small and large cell lung carcinoma (T2bN3M0, Stage IIIb) and treated with Chemoradiation. Vital signs were normal and he had coarse rhonchi over both lung bases. Laboratory evaluation showed anemia (hemoglobin, 110 g/L) and leukocytosis (WBC count, 13,800 k/µL). Chest CT scan showed erosion of the anterior wall of the left mainstem bronchus. On Bronchoscopy, it was covered with thick necrotic, purulent pseudomembrane (figure-1), densely adherent to the underlying bronchial wall. On microscopic examination of the BAL specimen, fungal hyphae morphologically consistent with Aspergillus species were seen (figure-2). The patient was started on Voriconazole and scheduled for insertion of bronchial stents but he developed massive hemoptysis later that evening and died.

DISCUSSION: ATB is classified into - (i) Ulcerative (ii) Obstructive, and (iii) Pseudomembranous type which has plaques of pseudomembranes but no airway obstruction and the slough contains Aspergillus hyphae. It manifests clinically with symptoms of fever, cough, dyspnea, pleuritic chest pain and hemoptysis. Physical examination is non-specific and unilateral wheeze in the absence of chronic airway disease may be the only localizing sign. Bronchoscopic examination with microbiologic analysis of the BAL or histopathology specimens is the mainstay of diagnosis. Radiologic imaging and serology for Galactomannan testing lacks sufficient diagnostic accuracy. For treatment, Voriconazole is currently used as the first line agent either alone or in combination with Amphotericin B or echinocandins. The duration of therapy is based on the nature of clinical and radiological response.1 Topical application of Amphotericin B on the tracheobronchial mucosa, endoscopic stricture dilatation, laser ablation and even endoscopic resection of necrotic tissue have also been tried as adjuvant therapy.

CONCLUSIONS: ATB occurs in immunocompromised patients and requires a high index of clinical suspicion for a timely diagnosis.

Reference #1: Fernández-Ruiz M, et al. Medicine (Baltimore). Aspergillus tracheobronchitis: report of 8 cases and review of the literature. 2012 Sep;91(5):261-73.

DISCLOSURE: The following authors have nothing to disclose: Anirudh Aron, Upasna Aron

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