SUPER DIMENSION NAVIGATIONAL BRONCHOSCOPE-ASSISTED MINI-BAL ROLE IN CASE OF FUNGAL BALL

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: Aspergillus species are ubiquitous and exposure to their spores is frequent. Aspergillosis can be confused with malignancy on imaging and sometimes creates challenge. The sensitivity and specificity of a positive result of BAL fluid are about 50% and 97%, respectively, but this diagnostic yield of BAL in the diagnosis of aspergillosis is not consistent. Eosinophilia is often reported in BAL of aspergillosis but degree of eosinophilia varies and may not be helpful. In this presented case we noted the mini-BAL performed at the site of fungal ball show significant elevation and high percentage of eosinophilia as compared to regular BAL and can be assuring in evaluation of mass for aspergilloma vs malignancy. CASE PRESENTATION: 79-year-old male ex-smoker treated with chemotherapy and radiotherapy for adenocarcinoma of the distal esophagus and had definitive surgery. He had been cancer free for 4yrs. Pt started having nonproductive cough without any fever, chills, rigors, chest pain, weight loss, hemoptysis or night sweats. Chest x-ray revealed 3.1 cm irregular and nodular opacity in right mid lung field and this finding was confirmed with CT scan. There were some infiltrates but no lymphadenopathy. Repeat CT scan showed mass in distal right upper lobe worsening in size. There was concern for endobronchial mass in right upper lobe. He went through Super-Dimension navigational bronchoscopy. Biopsy results confirmed no malignancy but there were gram-positive hyphae suggestive for Aspergillus species. Interestingly mini BAL through the working channel of super-dimension navigation al bronchoscope showed 38% eosinophils at the site of aspergilloma and regular BAL was having 11% eosinophils. He was given voriconazole and repeated CT scan showed significant improvement in Aspergillosis. DISCUSSION: Fungal balls can occasionally put potential diagnostic dilemma especially in a patient who had gone through the surgical and chemotherapeutic treatment of lung malignancy and are immunocompromised. Such patient can have a diagnostic challenge even after bronchoscopic approach if mass vs fungal ball is located in distal bronchi. Comparing the mini-BAL from the working channel of super dimension navigational bronchoscope from the site of the lesion to regular BAL can be reassuring for fungal etiology if there is a higher degree of eosinophilia from the site of lesion and empiric antifungal treatment trial can be considered in appropriately selected patients. CONCLUSIONS: Through the Super Dimension Navigational Bronchoscope working channel mini Bronchoalveolar lavage eosinophilic comparison with regular BAL can increase the sensitivity for the diagnostic yield for mycetoma if there is a higher percentage of eosinophilia is found at the site of lesion and can help to differentiate from other pulmonary eosinophilic conditions like lung malignancy, and other DPLDs. Reference #1: Hage CA, Reynolds JM, Durkin M, Wheat LJ, Knox KS. Plasmalyte as a cause of false-positive results for Aspergillus galactomannan in bronchoalveolar lavage fluid. J Clin Microbiol 2007; 45:676–7. Reference #2: Du Rand IA, Barber PV, Goldring J, et al. British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax 2011; 66(suppl 3):1–21. Reference #3: Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Aug 15;63(4):e1-e60. https://doi.org/10.1093/cid/ciw326. Epub 2016 Jun 29. DISCLOSURES: No relevant relationships by Amnah Andrabi, source=Web Response No relevant relationships by Kashif Aslam, source=Web Response No relevant relationships by Bindu Gandrapu, source=Web Response No relevant relationships by Preeyanka Sundar, source=Web Response