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A5426 - Pulmonary Aspergillus Overlap Syndrome - A Case Report
Author Block: J. Akhtar1, A. Lal1, R. Rosiello2; 1Internal Medicine, Saint Vincent Hospital, Worcester, MA, United States, 2Pulmonary Division, Reliant Medical Group, Worcester, MA, United States.
Introduction: Aspergillus is a ubiquitous fungus that causes a variety of clinical syndromes in the lung, ranging from aspergilloma in patients with lung cavities, to chronic necrotizing aspergillosis in those who are mildly immunocompromised or have chronic lung disease. Invasive pulmonary aspergillosis (IPA) is a severe and commonly fatal disease that is seen in immunocompromised patients, while allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to Aspergillus antigens that mainly affects patients with asthma. Although these are distinct pulmonary entities, on rare occasions may co-exist or may progress from one entity to another. Case Report: A 30 year old male having asthma, presented with complain of shortness of breath, cough and right sided chest pain for six weeks. He also have dark brown sputum with blood on few occasions. CT chest showed multilobar consolidations involving the bilateral lower lobes and right upper lobe. The areas of consolidation appear multilobulated and heterogenous with a peribronchovascular distribution. Significant bronchiectasis was noted within superior segment of right lower lobe associated with areas of bronchial wall thickening. A finger in glove appearance was also present. Serum IgE was elevated. IgE aspergillus fumigatus was positive. He was diagnosed with Allergic Bronchopulmonary Aspergillosis (ABPA) and was treated with oral steroid apart from inhaled bronchodilator and inhaled steroid. The shortness of breath and chest pain subsided, but there was still mild cough having black particles in sputum. He was treated with levofloxacin antibiotic for possible pneumonia as well. Repeat CT chest showed persistent right lower lobe opacity and extensive mucoid impaction in right upper lobe with air fluid level. There was worsening on left side, having severly dilated bronchi in anterior segment of left lower lobe, largely opacified and having air fluid level. Significant bronchiectasis was again revealed in right upper lobe, superior segment right lower lobe and left lobe. Due to worsening on left side, bronchoscopy was done, which revealed numerous fungal organisms consistent with Aspergillus fumigatus. Patient was also diagnosed with Chronic necrotising aspergillosis(CNPA). He was treated with voriconazole for 3 months duration for CNPA and oral steroid for ABPA. Patient responeded well both clinically and radiologically. Discussion: The proposed mechanisms for the development of Aspergillus overlap syndromes include coincidence, the presence of severe underlying lung disease, corticosteroid therapy, or Aspergillus fungal load. It is also possible that genetic factors may predispose patients to progress from one form of aspergillosis to another.