A 50-year-old male diabetic was diagnosed and treated for pulmonary tuberculosis 13 years ago. He presented with a 6-month history of low-grade fever and sweating. He also had frequent hemoptysis for the previous 3 months. He was investigated at his local hospital and referred to us for management of pulmonary aspergiloma. Examination was significant for low-grade fever and bronchial breath sounds with coarse crepitations in the right infrascapular region. A sputum smear was negative for acid-fast bacilli and grew Aspergillus. A plain chest x-ray showed a thick wall cavity in the upper and mid zone adjacent to the right hilum. A high-resolution CT scan revealed a large cavity in the apical segment of the right lower lobe with extensive lamellar internal echoes (Figure 1). Ultrasound of the abdomen revealed a simple hepatic cyst with no internal echoes. Bronchoscopy showed fresh blood and some necrotic material coming out of the superior segment of the right lower lobe. Culture of the material grew Aspergillus.
Wedge resection of the apical segment of the right lower lobe was performed due to persistent hemoptysis and growth of Aspergillus species in a possible post tuberculous cavity. Gross examination of the specimen revealed a surprisingly whitish membrane of the cyst wall with fungal necrotic material inside (Figure 2). Histopathological examination confirmed the presence of hydatid cyst along with echinoccocus hooklets with invasive Aspergillus within the cyst wall (Figure 2). Lung tissue around the cyst showed nonspecific chronic inflammation and an absence of fungal hyphae. The patient was treated for hydatid disease with albendazole and itraconazole for aspergillosis. The patient was free of any recurrence of either disease at the 8-month follow-up.
CT scan of the chest showing a cavity in the upper segment of the right lower lobe with lamellar internal echoes.