A CASE OF CHRONIC PULMONARY ASPERGILLOSIS IN A HEALTHY IMMUNOCOMPETENT PATIENT

Abstract

SESSION TITLE: Chest Infections: Find the Fungus SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/21/2019 3:15 PM - 4:15 PM INTRODUCTION: Chronic pulmonary aspergillosis (CPA), and specifically its most common form – chronic cavitary pulmonary aspergillosis (CCPA) - is an uncommon pulmonary disease (1). It may be seen in either patients are who are immunocompromised or patients who are immunocompetent with underlying lung disease. We present a case of CCPA complicated by recurrent hemoptysis necessitating surgical resection in a healthy 19-year-old female without known underlying lung disease. CASE PRESENTATION: A 19 year-old female presented with one month of hemoptysis. She was healthy, without any known medical problems until age 17 when she was found to have a mycetoma and cavitary pneumonia. She underwent an extensive workup, including HIV and Quantiferon Gold testing, at that time which was negative and was treated with antibiotics. She was unable to complete a prolonged course of voriconazole due to financial constraints. Interval imaging demonstrated multiple cavitary lesions with air fluid levels and soft tissue density consistent with aspergilloma. She was asymptomatic between age 17 and 19, when she began to experience hemoptysis. The patient presented to our hospital with persistent hemoptysis. She underwent robotic video-assisted thorascopic surgery (VATS) with right lower lobectomy. The parenchyma was noted to contain numerous cystic cavities. Histological examination demonstrated free-floating aspergillus hyphae within a cyst wall. Although not definitive, the aspergilloma may have formed in an area of interlobar pulmonary sequestration or congenital cystic adenoid malformation. Five days following surgery, the patient had no further hemoptysis and was discharged home. DISCUSSION: CCPA is a common form of CPA, which also encompasses aspergillus nodules, simple aspergilloma, and subacute invasive aspergillosis (SAIA) or chronic necrotizing pulmonary aspergillosis. Left untreated, CCPA may progress to chronic fibrosing pulmonary aspergillosis (CFPA), which is characterized by extensive pulmonary fibrosis. It is exceedingly unusual for CCPA to develop in immunocompetent individuals without underlying pulmonary disease. Our patient is a young and healthy female who had no prior respiratory symptoms who presented at the age of 17 with an already formed aspergilloma. Oral antifungal therapy is considered standard of care for treatment of CCPA (1). Response is slow and requires a minimum of four months. Hemoptysis may necessitate surgical resection in those with adequate pulmonary function. CONCLUSIONS: CCPA may occur in imunnocompetent patients with no prior history of lung disease. The possibility of the presence of a previously unknown and asymptomatic congenital malformation may increase the risk for the development of CPA. Reference #1: Denning DW, Cadranel J, Beigelman-Aubry C, et al. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. Eur Respir J 2016;47:45-68. DISCLOSURES: No relevant relationships by Craig Fryman, source=Web Response No relevant relationships by Sameer Khanijo, source=Web Response No relevant relationships by Kelvin Wong, source=Web Response