UCLA-West Los Angeles VA Healthcare Center, Los Angeles, CA
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Aspergillus pulmonary infection occurs in patients with underlying chronic lung disease with presentations ranging from mycetoma, to chronic cavitary pulmonary aspergillosis, CNPA, or invasive pulmonary aspergillosis (IPA). IPA is highly lethal and occurs in immunocompromised patients. CNPA is usually seen in patients with some degree of immunosuppression and is often referred to as a “subacute” or “semi-invasive” form of IPA. We describe a case of life threatening hemoptysis due to CNPA in an immunocompetent patient.
CASE PRESENTATION: A 69-year-old male smoker presented with dyspnea and hemoptysis. One month prior, he was treated for a right upper lobe (RUL) pneumonia with levofloxacin; M. tuberculosis was ruled out. Chest CT showed a RUL 11.6 x 6.5 cm cavitary lesion with an air fluid level (Fig 1A). Broad spectrum antibiotics were started. Diagnostic bronchoscopy grew an unspecified mold. Fluconazole was added for possible coccidioidomycosis. He developed massive hemoptysis on hospital day 9 requiring intubation. Emergent bronchoscopy confirmed extensive fresh blood from the RUL. Interventional Radiology embolized two RUL bronchial arteries, but patient continued with massive hemoptysis. Emergent RUL lobectomy done. Empiric voriconazole added for aspergillosis. Pathology demonstrated intracavitary mycetoma, necrotizing pulmonary aspergillosis but no vasculitis (Fig 1B). Cultures grew Aspergillus. He was discharged 21 days later on voriconazole and eventually returned to full time employment.
DISCUSSION: Clinical presentation of CNPA includes dyspnea, cough and hemoptysis. Radiological features include consolidation with cavity formation. Aspergillus serum antibodies are often positive. An indolent course with limited morbidity typically distinguishes CNPA from IPA. The confirmation of CNPA can be difficult and requires evidence of tissue invasion by hyphae in combination with a positive culture. Initial treatment for CNPA is azole therapy. Life threatening hemoptysis may require embolization or surgical resection.
CONCLUSIONS: The diagnosis of CNPA can be difficult. A high index of suspicion is needed for timely diagnosis. Presentation is non-specific and diagnosis is often delayed as patients are treated for bacterial pneumonia or assessed for mycobacterial disease. Sputum isolates of Aspergillus in immunocompetent individuals are often dismissed as colonization. This patient was not the typical patient with CNPA. He was immunocompetent without any previously diagnosed lung disease. He developed massive hemoptysis, yet pathology demonstrated limited tissue destruction, without vascular invasion. Immunocompetent patients with CNPA and massive hemoptysis are unusual with < 10 reported cases in the literature.
Reference #1: Denning DW, Riniotis K, Dobrashian R, Sambatakou H. Chronic cavitary and fibrosing pulmonary and pleural aspergillosis: case series, proposed nomenclature change, and review. Clin Infect Dis. 2003 Oct 1;37 Suppl 3:S265-80.
DISCLOSURE: The following authors have nothing to disclose: Oragun Rojanapairat, Timbrely Fong, Dhananjay Chatterjee, Tyler Larsen, Guy Soo Hoo, Jaime Betancourt
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