A 39-year-old man, apartment building labor, was referred to Masih Daneshvari Hospital, a university-affiliated respiratory hospital In Tehran, Iran in June 2022, complaining of high-grade fever, chills and shortness of breath. Dyspnea has been a complaint of the patient for 6 months, which has intensified since last month. There has been no evidence of hemoptysis, anorexia, or significant weight loss and no relevant personal history including atopy and allergic reactions in the past or family history such as tuberculosis or asthma has been reported. Additionally, he had no known recent COVID-19 exposures or history of a recent viral illness. A 20-year history of smoking cigarettes (20 packs per year) was also reported by the patient.
A temperature of 38.5 C, heart rate of 88 bpm, blood pressure of 115/80 mm Hg, oxygen saturation of 93%, and respiratory rate of 20 breaths/min were measured and arterial blood gas revealed hypoxemia and mild respiratory alkalosis. Examination of his chest showed reduced breath sound intensity on the left side. The rest of the physical examination was unremarkable.
The laboratory data showed an elevated C-reactive protein level (48 mg/dL) and eosinophil count (450/muL, reference range: less than 400/muL). The serum immunoglobulin (Ig) E level was 480 IU/mL (reference range: less than 150 IU/mL). Specific IgE and IgG to Aspergillus and anti-neutrophil cytoplasmic antibodies were negative.
Hydatid cyst and galactomannan serology tests resulted negative. In addition, the COVID-19 PCR test was negative.
Examination of a chest radiograph indicated left-sided pleural effusion (Fig. 1). Consequently, a computed tomography (CT) scan was requested, which demonstrated left-sided pleural effusion (Fig. 2).
The echocardiography confirmed proper cardiac function without any structural abnormalities. Additionally, there was no evidence of pericardial effusion. After that, a thoracocentesis was performed. A cytological examination of the pleural fluid revealed neutrophilia and nuclear debris (exudative pleural effusion with 6 x 10^3/microL leukocyte containing 80% neutrophil), but no malignant cells. Fig. 3 shows post-thoracocentesis radiography.
Further evaluation of the patient included bronchoscopy, which revealed the following: there were no tumoral lesions found, the opening of the LLL was obstructed with a thick mucoid plug that did not clear with suction, and several biopsies were obtained to assess the pathology.
Despite receiving a wide range of antibiotics (ceftriaxone, clindamycin, ceftazidime, meropenem, vancomycin, and levofloxacin) and glucocorticoid therapy, symptoms of the patient persisted, and no clinical improvement was observed. Finally, the patient was referred to the surgery ward, where he underwent surgery for lobectomy of the left lower lobe.
Gross pathology (Fig. 4) of the lesion was suggestive of endoluminal impaction but patient didn't meet the diagnostic criteria of ABPA (IgE = 480, galactomannan = negative).
Fig. 5 demonstrates the surgical pathology of specimens from left lower lobectomy of the lung, showing noticeably dilated and inflamed bronchus (A). Additionally, numerous degenerating eosinophils with relatively acellular mucin is observed (B and C). Furthermore, the gimsa staining was performed and no parasite or fungal infection have been detected.
Post-surgical follow up showed clinical improvement with no sign of previously persistent symptoms and eventually patient was discharged with good general condition.