WHEN A COUGH ISN'T ASTHMA; WHEN A MASS IS NOT CANCER

Abstract

Introduction The differential of chronic cough is broad and changes in the pattern of cough should be evaluated. We present a case with a surprising finding during our evaluation of worsening cough. Case description A 68-year-old female former smoker with a history of breast cancer status post mastectomy, asthma and allergic rhinitis presented with complaints of worsening cough, hoarseness, and intermittent dysphagia of 3 months duration. Chest radiograph revealed a 2.4 × 1.6 cm right upper lung (RUL) nodule. Chest computed tomography showed a 2.4 cm x 2.1 cm RUL mass, without cavitary lesions, and no evidence of bronchiectasis. Biopsy of this lesion revealed a mycetoma with no features of invasive aspergillosis. Upon further questioning the patient revealed having night sweats and right axillary pain; however, no hemoptysis. Labs were significant for elevated Aspergillus fumigatus IgE and no eosinophilia. She completed 6 months of treatment with decrease in aspergillus IgE and resolution of her symptoms. Simultaneous ENT evaluation revealed moderate arytenoid edema, where therapy with ranitidine therapy was initiated. Discussion We present a case of pulmonary aspergilloma discovered during an evaluation for worsening cough in an immunocompetent patient with asthma and no evidence of cavitary lung lesions or ABPA. The literature reports antifungals and/or surgery is the mainstay of therapy. Our patient's cough improved with simultaneous treatment for GERD and aspergilloma. Changes in cough patterns should prompt further evaluation and aspergilloma should be considered in the differential diagnosis of mass lesions. The differential of chronic cough is broad and changes in the pattern of cough should be evaluated. We present a case with a surprising finding during our evaluation of worsening cough. A 68-year-old female former smoker with a history of breast cancer status post mastectomy, asthma and allergic rhinitis presented with complaints of worsening cough, hoarseness, and intermittent dysphagia of 3 months duration. Chest radiograph revealed a 2.4 × 1.6 cm right upper lung (RUL) nodule. Chest computed tomography showed a 2.4 cm x 2.1 cm RUL mass, without cavitary lesions, and no evidence of bronchiectasis. Biopsy of this lesion revealed a mycetoma with no features of invasive aspergillosis. Upon further questioning the patient revealed having night sweats and right axillary pain; however, no hemoptysis. Labs were significant for elevated Aspergillus fumigatus IgE and no eosinophilia. She completed 6 months of treatment with decrease in aspergillus IgE and resolution of her symptoms. Simultaneous ENT evaluation revealed moderate arytenoid edema, where therapy with ranitidine therapy was initiated. We present a case of pulmonary aspergilloma discovered during an evaluation for worsening cough in an immunocompetent patient with asthma and no evidence of cavitary lung lesions or ABPA. The literature reports antifungals and/or surgery is the mainstay of therapy. Our patient's cough improved with simultaneous treatment for GERD and aspergilloma. Changes in cough patterns should prompt further evaluation and aspergilloma should be considered in the differential diagnosis of mass lesions.