AN UNUSUAL PRESENTATION OF ENDOBRONCHIAL ASPERGILLOMA

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Endobronchial aspergilloma (EBA) is a rare manifestation of pulmonary Aspergillosis characterized by growth of an Aspergillus species as a space-occupying lesion into the bronchial lumen. This can be an isolated manifestation of aspergillus, or occurs in association with parenchymal aspergilloma, allergic broncho-pulmonary aspergillosis, or necrotizing forms of pulmonary aspergillus.1 The clinical presentation of EBA is quite diverse, ranging from an asymptomatic state to dyspnea, cough, hemoptysis and weight loss. In most cases, EBA is found incidentally when patients undergo bronchoscopy for evaluation of other pulmonary symptoms. EBA can mimic endobronchial cancer or carcinoid due to similar clinical and radiographic presentation.1 CASE PRESENTATION: A 46-years-old female was admitted to hospital for surgical fixation of hip fracture after a fall. She also had exertional dyspnea with non-productive cough for past six months. She denied hemoptysis, chest pain, fever, chills and night sweats. Her past medical history included recurrent pneumonia, type I diabetes, end stage renal disease on hemodialysis, and right heart failure. Laboratory evaluations were unremarkable. Chest x-ray showed right upper lobe opacity superior to minor fissure. Computerized tomography (CT) scan of the chest (Figure 1) revealed right upper lobe consolidation with partial occlusion of the right upper lobe bronchus. A diagnostic bronchoscopy was performed to confirm the etiology. It demonstrated complete endobronchial obstruction of the anterior segment of the right upper lobe with cobblestone appearing white material. A biopsy demonstrated pseudohyphae (Figure 2). Polymerase chain reaction (PCR) of material was diagnostic of Aspergillus species. A final diagnosis of EBA was made and the patient was treated with antifungal (Voriconazole) therapy for 6 weeks with subsequent resolution of her symptoms. DISCUSSION: Aspergillus spp. have been associated with a wide spectrum of lung disorders, especially in immunosuppressed patients. Our patient had multiple comorbidities, but did not have typical risk factors for opportunistic infection, resulting in a low index of suspicion for invasive fungal disease. The diagnosis of EBA is challenging on cross-sectional imaging. Bronchoscopy with biopsy is mandatory to confirm the diagnosis of EBA.2 The morphology of fungal form found in our case was atypical for aspergillus, which required further confirmation with PCR testing. Medical management with antifungal therapy may be effective, however, a surgical approach is recommended in patients with massive hemoptysis and adequate lung reserve.3 CONCLUSIONS: A high index of suspicion is required for diagnosing EBA. Bronchoscopic evaluation of endobronchial masses, followed by histologic examination is critical in establishing a diagnosis of EBA. Early medical management with antifungal therapy may hasten resolution of infection. Reference #1: Huang D, Li B, Chu H, et al. Endobronchial aspergilloma: A case report and literature review. Exp Ther Med 2017;14(1):547-54. doi: 10.3892/etm.2017.4540 [published Online First: 2017/06/01] Reference #2: Ma JE, Yun EY, Kim YE, et al. Endobronchial aspergilloma: report of 10 cases and literature review. Yonsei Med J 2011;52(5):787-92. doi: 10.3349/ymj.2011.52.5.787 [published Online First: 2011/07/26] Reference #3: Pohl C, Jugheli L, Haraka F, et al. Pulmonary aspergilloma: a treatment challenge in sub-Saharan Africa. PLoS Negl Trop Dis 2013;7(10):e2352. doi: 10.1371/journal.pntd.0002352 [published Online First: 2013/11/10] DISCLOSURES: No relevant relationships by Yumna Gulzar, source=Web Response No relevant relationships by Richa Purohit, source=Web Response No relevant relationships by stephen Selinger, source=Web Response No relevant relationships by Muhammad Yousaf, source=Web Response