A 45-year-old female patient, a city greening worker and was in good health before onset, was admitted to a local hospital in October 2017 due to cough and hemoptysis. At that time, she was diagnosed with pneumonia and bronchiectasis. She was given cephalosporin anti-infective therapy, but it did not work. Then, between January and March 2018, she visited other hospitals several times and was diagnosed with tuberculosis due to imaging findings (no Mycobacterium tuberculosis was found in sputum). Therefore, from April 2018 to April 2019, the patient received conventional (2HRZE/9HE) anti-TB therapy for about 1 year, but it was ineffective; cough and hemoptysis continued to occur repeatedly. Therefore, in November 2019, she came to our hospital for treatment. After admission, tuberculosis bacteria culture in sputum in November 2019 showed no M. tuberculosis complex group. Blood tests showed that the WBC was 5.42 x 109/L, the percentage of neutrophil was 0.77, the erythrocyte sedimentation rate was 58mm, PCT was 0.078ng/mL, and the C-reactive protein was 62mg/L; sputum smear was negative for acid-fast bacilli; and HIV antibodies were negative and antinuclear antibody was positive (1:1000). CTPA showed the following: Filling defect was observed in the main pulmonary artery, bronchial artery diameter was widened, and irregular patchy and nodular density was observed in both lungs (Figure 1A and B). Fiber-optic bronchoscopy was performed, which revealed a large amount of purulent secretions, bronchoalveolar lavage fluid (BALF) fungi (1-3)-beta-d glucan: 728.06, and GM test: 3.239. Pleomorphic fungi were observed by gram staining of BALF smear (Figure 2A and B). Acid-fast bacilli were not found in BALF smear and brush smear. Cryptococcus latex agglutination test was negative. No bacteria were cultured in BALF. No bacteria, fungi, viruses, parasites, M. tuberculosis, mycoplasma, chlamydia, or rickettsia were found by mNGS (BALF).
CTPA and bronchial arterial angiography showed left bronchial artery-left pulmonary artery shunt (Figure 1A and B) and right bronchial artery-right pulmonary artery shunt. Fungal hyphae and spores were observed by gram staining of BALF smear. Two consecutive BALF fungal cultures grew A. mycotoxinivorans (Figure 2A and B), the identity of which was confirmed by internal-transcribed-spacer (ITS) sequencing. The phagocytosis of A. mycotoxinivorans by leukocytes was observed under the microscope (Figure 3). Intravenous amphotericin B liposome (30mg; 0 5mg/kg, QD) was given for 2 weeks, embolization was performed, and itraconazole (voriconazole allergy) was taken orally for 9 months after operation. Hemoptysis and pulmonary lesions gradually improved after treatment. Fiber-optic bronchoscopy was performed once again. Acid-fast bacilli were found on BALF smears two times, and Mycobacterium intracellulare was detected by mNGS. Oral rifabutin (0.3g qd), ethambutol (15-25mg/kg d), and clarithromycin (0.5, bid) were given for 6 months at the same time. The patient had clinical remission of pulmonary infection. After infection control, oral methylprednisolone (30mg qd) and hydroxychloroquine (0.2g bid Po) were given for 2 months for SLE. Re-examination of the lesion showed absorption, and no hemoptysis occurred in the patient after 6 months of follow-up.