An 80-year-old Japanese female, with a 48-pack years smoking history, presented to a clinic complaining of wet cough and breathing difficulty. She had a past history of tuberculosis, but there was no history or symptoms suggestive of asthma. Chest radiograph revealed left lower lobe collapse (Fig. 1). She was hospitalized after being diagnosed with pneumonia and treated with antibiotics (ampicillin/sulbactam). However, the initial treatment was ineffective, and radiograph findings progressively worsened within weeks. Therefore, she was transferred to our hospital for evaluation and treatment at one month after symptom onset.
Upon examination, SpO2 was 89% at room air. Laboratory test showed elevated eosinophil count at 651/muL. Additionally, chest radiograph and computed tomography (CT) findings revealed complete collapse of the left lung with hyperattenuated mucoid (HAM) impaction (Fig. 2). Bronchoscopy showed a white, rubbery, thick mucus plug in the left main bronchus, which could not be removed by forceps or suction (Fig. 3). The findings on pathologic examination were eosinophilic infiltration without Charcot-Leyden crystals on Hematoxylin and Eosin stain and presence of fungal mycelium on Grocott stain. Culture of the small pieces of the mucus plug obtained during bronchoscopy yielded S. commune.
The patient was treated with an expectorant agent, bromhexine 8 mg three times daily, after the bronchoscopy. Three weeks later, chest radiographic findings revealed improvement of the collapsed left lung (Fig. 4A). Two months later, while she was completely recuperating from wet cough and breathing difficulty, SpO2 increased to 97% at room air and chest CT showed complete recovery of the collapsed lung, but with central bronchiectasis seen (Fig. 4B). Subsequently, she has returned to the clinic for follow-up and has continued bromhexine treatment successfully for more than 20 months. There were no adverse effects of bromhexine.
Chest computed tomography obtained upon admission shows complete collapse of the left lung with hyperattenuated mucoid impaction.