This patient is a 57-year-old male with a past medical history of tuberculosis and a significant social history of chronic cocaine use who presented to the emergency department due to progressively worsening dyspnea over the last three months. On physical exam, the patient had diffuse wheezing. He also endorsed a 20-pound weight loss over the last three months and increased urinary retention. The patient denied fevers, chills, recent travel, hemoptysis, and cigarette smoking.
During his hospital stay, the following labs were performed: Acid-fast bacilli smear, Mycobacterium polymerase chain reaction, Legionella antigen, urine drug screen, immunoglobulin E (IgE) levels, Aspergillus antigen, and neutrophilic cytoplasmic antibody. Acid-fast bacilli testing was negative, as well as mycobacterium polymerase chain reaction, Legionella antigen, and neutrophilic cytoplasmic antibody. Urine drug screen was positive for cocaine. Eosinophil count was elevated at 670 cells/muL (normal < 610 cells/muL). IgE level was also elevated at 2,378 kU/L (normal < 114 kU/L). Based on findings of elevated IgE levels, IgE against Aspergillus fumigatus was sought out and came back positive (0.56 kU/L).
Chest X-ray revealed hyperinflation, flattened diaphragm, and pleural thickening (Figure 1). Chest CT without contrast revealed some bronchial wall thickening and bronchiectasis in the bilateral lower lobes (Figure 2(a)). In the right upper lobe, there was also some bronchial wall thickening, bronchiectasis, and tree-in-bud nodularity (Figure 2(b)). A 1.0 x 2.2 x 1.8 cm solid nodule was visualized in the posterior medial right lung (Figure 2(c)). This was grossly stable in size from a chest CT 3 months prior.
The patient was first treated at an outside hospital for pneumonia with amoxicillin-clavulanate and a 7-day course of prednisone 10 mg at the first onset of his symptoms. He reported transient improvement with steroids. On presentation, prior to confirmation of ABPA, the patient was treated with 60 mg intravenous methylprednisolone BID and inhaled ipratropium bromide with albuterol sulfate. Once ABPA was confirmed, the patient was transitioned from methylprednisolone to a 4-day treatment course with 60 mg oral prednisone. The patient noted significant improvement prior to discharge.
Given the concern for malignancy due to significant weight loss and urinary retention, the prostate-specific antigen (PSA) was measured. This was elevated at 11.2 ng/ml (normal < 4.0 ng/ml). Urology was consulted, and outpatient follow-up with urology was recommended for a transrectal ultrasound- (TRUS-) guided biopsy.