909: MULTIPLE ARTERIAL COLLATERALS TO AN ASPERGILLOMA CAUSING RECURRENT HEMOPTYSIS

Abstract

Introduction: Aspergillus is a fungus that is ubiquitous in the environment and causes various clinical syndromes depending on host characteristics. The spectrum of disease affects 3 million people worldwide and ranges from an asymptomatic fungal ball to lung destruction. We present a patient with a history of tuberculosis and pulmonary aspergilloma which parasitized multiple arterial sources including the bronchial artery, internal mammary artery, and several subclavian artery branches with venous fistulization. Description: A 79-year-old man presented with 6 months of daily hemoptysis. His past medical history was significant for diabetes mellitus, severe centrilobular emphysema, mycobacterium avium complex infection, and previously treated tuberculosis. A computed tomography scan of the chest demonstrated a left upper lobe (LUL) mass with cavitation. He underwent flexible bronchoscopy with bronchoalveolar lavage and endobronchial biopsy of the LUL. The fungal culture grew Aspergillus fumigatus which correlated with the biopsy which revealed a conglomerate of septate hyphae consistent with an aspergilloma. He was referred for bronchial artery angiogram with embolization. During the procedure multiple arterial feeders to the aspergilloma were identified. This included the left bronchial artery, left internal mammary artery, left superior thoracic artery, left thoraco-acromial artery and left lateral thoracic artery. Each of these arteries supplying the aspergilloma demonstrated the added complexity of venous fistulization. Due to the presence of venous fistulas, embolization was performed using n-butyl cyanoacrylate with lipiodol. Considering the patient’s clinical stability, length of procedure and radiation time and contrast administered, as well as the absence of active bleeding during the procedure, the left internal mammary artery and left thoraco-acromial artery were not embolized with the intent of a follow-up procedure. Discussion: Chronic pulmonary aspergillosis can cause life-threatening hemoptysis when arterial feeders develop to supply an aspergilloma. First line treatment options include bronchial arterial embolization. This case highlights the unusual presentation of an aspergilloma that both parasitized numerous systemic arteries while forming venous fistulas, a rare phenomenon.