WELL, THAT ESCALATED RATHER QUICKLY: A CASE OF RAPIDLY PROGRESSIVE SUBACUTE INVASIVE PULMONARY ASPERGILLOSIS

ABSTRACT

SESSION TITLE TB and TB-Involved Case Posters SESSION TYPE Case Report Posters PRESENTED ON 10/17/2022 1215 pm - 0115 pm INTRODUCTION: Pulmonary Aspergillus infection has a wide array of manifestations. Chronic Pulmonary Aspergillosis is an uncommon progressive respiratory disease, with the Subacute Invasive Pulmonary Aspergillosis form, one of the most challenging to manage. Typically it presents with rapidly progressive infection (of less than 3 months) in mild to moderately immunocompromised patients with underlying structural lung disease. We herein report the case of a 69-year old female with post-tuberculous cavity with disease progression, in approximately 6 weeks, associated with Aspergillus infection. CASE PRESENTATION Patient is a 69-year old African American female, never smoker, with known history of Type 2 Diabetes Mellitus and previously treated mycobacterium tuberculosis with residual small right upper lobe cavity (measuring approximately 35 x 40 mm). She was being followed in our outpatient thoracic oncology clinic with serial imaging for surveillance, CT Chest initially every 3 - 6 months then annually thereafter with PET scan as clinically indicated. The cavity remained relatively unchanged for approximately 5 years. In October 2021, her CT Chest had revealed a stable cavity, even despite SARS-CoV-2 Pneumonia infection the previous year. The following month she was admitted to an outside hospital for hyperglycemia with notable significant increase in size of the right upper lobe cavity to 69 x 72 mm with surrounding nodularity. She completed a course of antibiotics and was seen in our clinic 3 months post discharge with a repeat CT Chest which now revealed a mass like area of consolidation with large area of lucency and superimposed fungus ball (now measuring 80 mm x 70mm). She underwent Electromagnetic Navigational Bronchoscopy with transbronchial biopsy and right upper lobe bronchoalveolar lavage. BAL culture identified Aspergillus niger, with no other pathogens (including acid fast bacilli isolated) or malignant cells observed. Biopsy revealed marked mixed inflammation and fungal hyphae. Patient is currently undergoing long-term oral antifungal therapy with plan for close surgical follow-up. DISCUSSION: The diagnosis of Chronic Pulmonary Aspergillosis requires a combination of clinical, radiological and histopathological characteristics present for atleast 3 months for diagnosis. This includes the presence of one or more cavities on thoracic imaging, evidence of aspergillus infection or an immunological response to aspergillus as well as excluding alternative diagnoses. Advances in diagnostic tools have improved early diagnosis and subsequent management as noted in our case. Surgical resection is recommended for simple aspergilloma, however rapidly progressive disease processes are recommended to be managed as invasive aspergillosis. CONCLUSIONS: Post-tuberculosis chronic pulmonary aspergillosis is an emerging disease with significant associated morbidity and likely health burden. Reference #1 Chronic pulmonary aspergillosis rationale and clinical guidelines for diagnosis and management David W. Denning, Jacques Cadranel, Catherine Beigelman-Aubry, Florence Ader, Arunaloke Chakrabarti, Stijn Blot, Andrew J. Ullmann, George Dimopoulos, Christoph Lange European Respiratory Journal Jan 2016, 47 (1) 45-68;DOI 10.1183/13993003.00583-2015 Reference #2 Bongomin F. Post-tuberculosis chronic pulmonary aspergillosis An emerging public health concern. PLoS Pathog. 2020;16(8)e1008742. Published 2020 Aug 20. doi10.1371/journal.ppat.1008742 DISCLOSURES No relevant relationships by Omotooke Babalola No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Sulaiman Tijani