PULMONARY ASPERGILLOMA WITH SUBCUTANEOUS FISTULA RESULTING IN MASSIVE HEMOPTYSIS & SUBCUTANEOUS EMPHYSEMA

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Aspergillomas growing in pre-existing lung cavities can lead to presentations of hemoptysis. We present a case of a 73-year-old male with NSCLC and known 4 cm left cavitary lesion presenting with cough and hemoptysis. This lead to the diagnosis of a pulmonary aspergilloma with chest wall subcutaneous emphysema due to cavitary-subcuteanous fistula. CASE PRESENTATION: A 73-year-old male with severe COPD, CAD, and NSCLC in the left upper lobe treated with chemoradiation and known cavitation arrived with cough and hemoptysis. Vitals were pertinent for tachypnea and hypoxia at 75% room air requiring BiPAP. His physical exam was notable for rales and rhonchi bilaterally. He was stabilized and treated for presumed pneumonia and COPD exacerbation. His hemoptysis was initially attributed to his known lung malignancy and anti-platelet agents. A CT Angiogram was negative for pulmonary embolism, but the cavitary lesion increased to 7 cm with a new increase in soft tissue density. Labs of note were WBC 21.1 x10 3/uL, hemoglobin 7.0 mg/dL, platelets of 304 k/uL. Beta-1,3-D-Glucan levels were < 31 pg/mL, and galactomannan EIA test index < 0.5. Blood cultures were negative. Sputum cultures were obtained with pending results. The patient continued to experience excessive cough and hemoptysis. Given the evolution of the left cavitary lesion, and the potential for infection occupying that space, he underwent CT-guided aspiration. In the preprocedural scan, an interval of two days from prior imaging, the amount of hyperdense material contained within the cavity had significantly decreased with an air-fluid level present. Furthermore, moderate subcutaneous emphysema in the left chest wall and axilla were noted, raising the question of a pleuro/broncho-cutaneous fistula between the air-filled cavity and tissues. Aspirate cultures returned with heavy growth of Aspergillus species, along with Aspergillus in the fungal cultures. He was started on voriconazole therapy and transferred to an outside facility for IR embolization due to continued massive hemoptysis. DISCUSSION: Aspergillomas can occur in patients with COPD and a history of a cavitary lesions. They can be asymptomatic. Rarely, aspergillomas can progress to invasive aspergillosis via mechanical friction or invasion of blood vessels leading to massive hemoptysis. Here, we present a case of a pulmonary aspergilloma which was complicated by chest wall subcutaneous emphysema. As far as we are aware, in a review a literature, this complication has not arisen. CONCLUSIONS: We present a case of an aspergilloma within a previous pulmonary cavity causing a cavitary-subcutaneous fistula without evidence of invasive aspergillosis resulting in subcutaneous emphysema. This shows that pulmonary aspergilloma could rarely invade the chest wall and sheds light on subcutaneous emphysema as a potential rare complication of aspergillomas without prior trauma. Reference #1: Warris, A. (2014). The biology of pulmonary aspergillus infections. Journal of Infection, 69, S36-S41. DISCLOSURES: No relevant relationships by Anthony Bekasiak, source=Web Response No relevant relationships by Aya Shnawa, source=Web Response No relevant relationships by John Tedrow, source=Web Response