Chronic Pulmonary Aspergillosis Progressing to Invasive Disease

Abstract

SESSION TITLE: Fungal Infections 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary aspergillosis has a wide clinical spectrum. Distinctions can be made between invasive versus non-invasive disease and chronic versus acute disease; this helps guide treatment and follow-up. Our patient proposes an interesting discussion; she presents with an overlapping chronic clinical picture with features of both invasive (Chronic Necrotizing Pulmonary Aspergillosis (CNPA)) and non-invasive (Chronic Pulmonary Aspergillosis (CPA)) disease. CASE PRESENTATION: A 74-year old lady with a history of breast cancer (status-post lumpectomy and radiation), COPD, and smoking, presented complaining of fatigue and cough. A lesion in the chest was incidentally appreciated on screening mammogram. A chest X-ray demonstrated a nodule in the right upper lobe (RUL) of the lung. Suspecting malignancy, a PET scan was done demonstrating nodules in the RUL, right middle lobe, and left upper lobe, with imaging favoring an inflammatory versus malignant process. She was treated for an upper respiratory tract infection. On six week follow-up, her symptoms persisted and a CT-scan showed new nodules in the RUL and lingula. Needle biopsy showed fungal colonization, necrosis and giant cell reaction with adjacent fibrosis. Subsequent testing revealed elevated Aspergillus fumigatus IgE levels, normal IgG levels and negative Galactomannan antigen. She was treated with Itraconazole and remained stable without progression of disease. DISCUSSION: Pulmonary Aspergillosis often presents with non-specific symptoms overlying chronic respiratory disease. Our patient presented with cough and fatigue in the background of COPD and chest radiation. But for incidental mammogram findings, her symptoms could have been attributed to chronic disease and diagnosis may have been missed. A high index of suspicion is needed for timely intervention to prevent progression of disease. Classically, CPA presents with non-progressive nodules, fungal balls or peri-cavitary infiltration. Whereas CPNA presents with progressive infiltrates cavitating over 3 months or less. Our patient presented with lung nodules suggestive of nodular CPA. Subsequent development of new nodules indicated progression, raising suspicion for CPNA. Ultimately, biopsy findings did not demonstrate the cavitation characteristically seen in CPNA. Given concern for invasive disease, anti-fungals were prescribed. CONCLUSIONS: This unique case places the concept of CPA and CPNA being distinct entities under scrutiny. It suggests that they may represent a spectrum of the same disease. Our patient’s progression from non-invasive to invasive Aspergillosis could be attributed to localized pulmonary immunodeficiency secondary to emphysematous lung disease and radiation. It is important to suspect a necrotizing process with risk of fibrosis or invasion in patients with CPA, especially if localized lung immunosuppression is suspected. Reference #1: Pulmonary aspergillosis: a clinical review. Kousha M1, Tadi R, Soubani AO. Eur Respir Rev. 2011 Sep. DISCLOSURE: The following authors have nothing to disclose: Reema Qureshi, Patricia Russo-Magno No Product/Research Disclosure Information