A 46 years old man came to emergency unit with a chief complaint of shortness of breath for eight months that was getting worse in the last two months. This condition was getting worse, especially when he had vigorous activity. He also had cough with a red-black blood streak and foul odor sputum for three months. He had a history of two episodes of pulmonary TB that was cured after six months of therapy. He was diagnosed with a cerebral abscess and underwent cerebral surgery one year before. The patient works in textile fabric with dusty environment, but he rarely used masks. The patient also smoked ten cigarettes per day since he was 18 years old, but stopped when he was diagnosed with pulmonary TB.
On physical examination, the patient was alert with increased respiratory rate and decreased oxygen saturation. Head and neck examination showed dyspnea and slight conjunctiva anemic. Chest examination showed decreased right lung movement and vesicular breath sounds in the two-thirds superior right hemithorax.
Chest X-ray showed an air crescent with consolidation leading to an impression of lung mass and fibroinfiltrates in the superior and medius lobe of the right lung (Fig. 1). A contrast CT scan showed a consolidation (40 HU), cavities, air crescent signs, fungus ball, and pulmonary inflammatory process in the anterior segment superior lobe of the right lung (Fig. 2). Laboratory examination showed anemia (Hb 6.6 g/dL), leucocytosis (WBC 11.15 x 103/muL), neutropenia (neutrophils 54.1%) and low tumor marker (AFP 5.7 ng/mL, CEA of 2.12 ng/mL). Blood gas analysis showed fully compensated respiratory acidosis with mild hypoxemia. Mycobacterium tuberculosis (MTB) was not detected in the GeneXpert MTB/RIF sputum examination. We also did a sputum culture that grew fungal hyphae of Aspergillus fumigatus.
Spirometry examination showed moderate restrictions with no obstruction results. Cytology examination from left and right bronchoalveolar lavage revealed no malignant cells. Fine needle aspiration biopsy (FNAB) guiding CT examination found suppurative inflammation with atypical epithelial cells (reactive cell change) and cavity lesion.
Based on clinical symptoms, radiology imaging, and sputum culture, we manage the patient with a working diagnosis of aspergillosis. The patient was then consulted to thoracic and cardiovascular surgeons. Superior and medius lobectomy (bilobectomy) and adhesiolysis were performed (Fig. 3). During the surgical procedure, we accidently found an endobronchial nodule. Histopathology of lung tissue, fungal ball, and endobronchial nodule found aspergillus colonies and hamartoma features, as seen in Fig. 4. Meanwhile, the left lung lymph nodes cytology showed no tumor cell metastasis.
The patient has been treated with antifungal micafungin 200 mg intravenously once a day for one month and other supportive therapy. The patient's condition gradually improved after medication. He was discharged after thirty-day hospitalization with oral antifungal therapy of 100 mg/day fluconazole for 14 days.