Locally Invasive Fungal Lung Disease and Exercise-Induced Pulmonary Hemorrhage: A Deadly Interplay of Cavitary Aspergilloma Kinetics and Capillary Hemodynamics

Abstract

SESSION TITLE: Chest Infections II: Student Resident Case Report Posters SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Aspergilloma is an opportunistic fungal disease which typically forms in cavitary lung. We report the case of an enlarging aspergilloma in an immunocompromised patient with pulmonary hemorrhage precipitated by strenuous cardiopulmonary exercise. CASE PRESENTATION: A 58-year old female presented to our emergency department in February 2015 with hemoptysis. She underwent a multi-stage treadmill cardiac stress test seven days earlier to evaluate exertional dyspnea, achieving a heart rate of 143 and a peak blood pressure of 175/100. She subsequently coughed several teaspoons of blood streaked sputum for the next week. Prior to admission she ran vigorously at her gym triggering large-volume hemoptysis (130-150ml), prompting hospital admission. Her past medical history included fully treated pulmonary tuberculosis with residual localized cystic bronchiectasis in right upper lobe with a suspected aspergilloma and Crohn's disease in remission on azathioprine and mesalamine. On arrival her blood pressure was 162/86, pulse 72, afebrile with a resting SpO2 of 100% on air. Examination was significant for coarse breath sounds in the right upper chest. Labs revealed a hemoglobin of 14.5g/dl, WBC 6,600/nL, platelets 223,000/nL, INR 0.9 and PTT 20secs. Initial CT imaging demonstrated an enlarged lobulated right apical cavity containing a soft tissue mass, which had increased in size from 19.6mm to 22.4mm over 4 months. The patient was treated with piperacillin-tazobactam for an infectious exacerbation of bronchiectasis and her blood pressure was tightly controlled with beta-blockade. Her hemoptysis ceased by hospital day 4 without need for blood transfusion or endovascular intervention. Azathioprine was discontinued and voriconazole was initiated to minimize the risk of local fungal invasion. She was counselled on the importance of blood pressure control and advised to change her exercise routine from running to a low impact activity such as cycling to minimize aspergilloma movement and prevent shearing forces within the cavity. DISCUSSION: Aspergillomas confer significant morbidity to predisposed individuals with potential for life-threatening hemoptysis. Immunosuppression may facilitate local invasion of hyphae into the adjacent lung parenchyma. The delicate granulation tissue lining the cavity is probably susceptible to pendulous forces of the aspergilloma during high impact exercise such as running and jumping resulting in capillary rupture and bleeding1. CONCLUSIONS: There is little guidance on what lifestyle modification is appropriate for patients with aspergillomas. Providers should consider the exercise tolerance of each patient, their immune status and size of the aspergilloma before recommending a type and intensity of exercise that can safely be undertaken. Reference #1: Corrin, B. (2011). Pathology of the Lungs. Churchill Livingstone/Elsevier DISCLOSURE: The following authors have nothing to disclose: Haider Ali, Erika Diaz-Narvaez, Armando Cuesta, Schantal Polanco, Chang Shim, Virginia Chung No Product/Research Disclosure Information