A 27-year-old man was admitted to our emergency department complaining about cough, recurrent episodes of hemoptysis and B symptoms (weight loss and nocturnal sweating) that had persisted for several weeks and coming to a crescendo. Upon presentation, physical examination was strictly. The patient was free of medical issue, recent corticotherapy and addiction. He had been living in Belgium for six months and previously lived many years in Spain and Morocco.
Basic investigations were subsequently performed in the emergency unit at day 0. The results of the laboratory tests disclosed that the eosinophil count was significantly high (1.46 x 103/mm3). C-Reactive Protein, white cells count and d-dimers were normal. A lung CT scan was performed and showed bilateral apical ground-glass opacities associated to an atypical condensation in the left upper lobe apical segment (Fig. 1). The patient was then hospitalized and underwent bronchoalveolar lavage (BAL) at day +1. Cultures, Ziehl-Neelsen staining for mycobacteria and PCR Mycobacterium tuberculosis were negative.
In view of the persistent and worsening hemoptysis, patient underwent thoracoscopic wedge resection of the concerned left upper lobe at day +3. The thoracoscopic exploration was marked by a blackish indurated mass on the left upper lobe which was therefore resected. Pathologic examination revealed the presence of foci of pneumonia with numerous eosinophilic polynuclear cells (Fig. 2).
The following days in our department were marked by complete resolution of symptoms without benefit of any treatment. A thorough etiological laboratory test was performed at day +5, such as auto-immune tests (anti-nuclear antibodies and anti-neutrophil cytoplasmic antibodies), complement system markers (C3, C4 and CH50), protein electrophoresis, HIV serology, lymphocytic count (CD4+/CD8+) and immunoglobulins (IgM, IgA and IgG). No abnormalities were found but lingered a persistent hypereosinophilia. Interferon-gamma release assays (IGRA) and direct examination on sputum smear were negative. Serum galactomannan optical density index was also negative.
Anatomopathological examination showed features consistent with a bronchiolitis obliterans organizing pneumonitis and marked hypereosinophilia. No branching hyphae were observed. A PET-CT was performed at day +8 and displayed moderately hypermetabolic changes at the apex of the left lung (place of wedge resection) but no other hypermetabolic lesion. A corticosteroid therapy based on methylprenisolone 64mg was started at day +7.
As the follow-up was completed and the patient relieved from his symptoms, he was discharged 10 days after admission while tapering off the oral corticotherapy. However, a few days later, microbiology culture of the lung sample revealed black colonies with a granular appearance whose microscopic characteristics were reminiscent of Aspergillus niger (Fig. 3) leading us to consider the diagnosis of IPA. PCR Aspergillus on the lung sample was positive with a low cycle threshold (17 cycles). Corticotherapy was immediately stopped and the patient went on oral Voriconazole 200mg twice daily, without loading dose, for 6 weeks.
Compliance and tolerance were excellent. No adverse effect was encountered during those 6 weeks. However, a week after treatment withdrawal, the patient noticed the quick resurgence of the same symptoms that had initially brought him to the emergency room (especially hemoptysis and asthenia). By performing a chest scan, we highlighted the presence of a consolidation at the operative site. The patient therefore benefited from a treatment by itraconazole 200mg twice daily for another 6 weeks. The evolution was quickly spectacular and there have never been any new relapses to this day (2 years follow-up). The indoor environment analysis service was asked to inspect the patient's workplace and home but no Aspergillus was found.
Chest CT showing the condensation in the left upper lobe (red arrows). The bilateral ground glass opacities are not present on this section. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article. ).