A 27-year-old Peruvian male was admitted to our hospital because of fever, chills, productive cough, and chest pain. The patient had been in his usual state of general health until three months earlier when he began to notice some chest discomfort which was pleuritic in nature. The pleuritic chest pain was soon followed by the development of fever and productive cough. After a couple of weeks, the patient presented to a different hospital. At that hospital he was treated for lung abscess of the lingular lobe with clindamycin and an aminogylcoside for a period of four weeks, with little radiographic or clinical improvement. The patient was eventually discharged and presented to the emergency room several weeks later with no resolution in his symptoms.
There was no history of dyspnea, hemoptysis, seizure disorder, or alcohol or drug abuse. He denied any history of sick contacts. The patient was born and raised in Peru and had worked as a farm laborer prior to his migration to the United States five years prior to presentation. The patient had a history of contact with all domestic and farm animals while living in a farming village inland from Lima in his native Peru.
Physical examination on admission to the hospital showed a young, toxic-looking male with an oral temperature of 102 degrees Fahrenheit, a pulse rate of 120 beats per minute, respiratory rate of 20 breaths per minute, oxygen saturation of 95%, and a blood pressure of 110/70 mmHg.
Abnormal physical findings were confined to the chest, which showed bronchial breath sounds, an impaired percussion note, and few rales over the left lower chest anteriorly and laterally. There was mild clubbing of the fingers. Examination of the heart and the abdomen was unremarkable.
Initial white blood cell count was 10,900, with 60% polymorphonucleocytes, 7% band formations, 17% lymphocytes, 3% monocytes, and 13% eosinophils. A comprehensive metabolic panel, remaining complete blood count, and electrocardiogram were unremarkable. The chest radiograph (Fig. 1) showed a large thick-walled cavity involving the lingular lobe, containing an irregular wavy fluid level, suggestive of floating particulate matter ("waterlily sign"). A left lateral decubitus chest film confirmed mobility of the contents of the cavity.
Eventual gram stain of the sputum showed polymorphonucleocytes with mixed bacterial flora but the culture was negative. Computed tomography of the chest also supported the findings noted on the chest radiograph and failed to disclose any intrahepatic or abdominal abnormalities.
A fiberoptic bronchoscopic examination showed mucosal inflammation and mucopurulent secretions in the lingular and left lower lobe bronchi. The airways were patent. A fistulous communication between the accessible airways and the cavity was not identified. Bronchial washings were negative for malignant cells and for acid-fast bacilli on smear examination. An intermediate strength purified protein derivative (tuberculosis) skin test showed a 15 mm induration.
The patient was initially treated with clindamycin 600 mg intravenously every six hours for a period of ten days without a substantive clinical response. A. fumigatus had been isolated from bronchial washings. This information, coupled with a positive serum precipitin test for A. fumigatus, supported the diagnosis of an aspergilloma in a chronic abscess cavity. A Casoni test was not done. The patient underwent thoracotomy and resection of the lingular lobe.
Gross examination of the surgical specimen (Fig. 2) revealed the cavity to be a hydatid cyst that was 7.5 cm in its largest diameter. The cyst consisted of an outer shell, the ectocyst, with a glistening white inner surface. Contained within was a pearly membranous structure, the endocyst, lying in a pool of turbid brownish fluid. The surrounding lung parenchyma was compressed and firmly adherent to the outer surface of the ectocyst. Microscopic examination of the fluid sediment (Fig. 3) disclosed several hooklets and other remnants of scolices diagnostic of cystic echinococcosis. Histologic examination of the pericyst (Fig. 4) showed inflammatory changes and infiltration by numerous septate hyphae consistent with Aspergillus species. A. fumigatus was isolated on culture from the cystic fluid. Bacterial culture of the cystic fluid was negative.
Following surgical resection of the hydatid cyst, the patient recovered uneventfully and became afebrile on the sixth post-operative day. There were no postoperative complications. The patient has remained in good health and has failed to show recurrence for three years after thoracotomy.