A 24-year-old black man, presented with an one-month history of productive cough, weight loss and malaise. He was diagnosed to have systemic lupus erythematosus 6 years ago and he had pulmonary tuberculosis 4 years ago and for this he received one year of antituberculosis treatment. Furthermore he underwent renal transplant 3 years ago, and developed post-transplant diabetes mellitus. He was receiving prednisone, tacrolimus and rapamicine. He had never smoked and there was no history of alcohol abuse.
Physical examination showed the patient to be ill-looking, emaciated, acianotic, and afebrile. Blood pressure of 100/70 mmHg, pulse rate of 80 beats per minute and respiratory rate of 22 breaths per minute. Laboratory tests showed the following: hemoglobin- 9,60 g/dl, hematocrit- 30,4%, leukocytes- 8200/cu mm (49% segmented neutrophils, band- 2%), lymphocytes- 22%. Prothrombin time were 50% (16"1 versus 11"5 control value), International Normalized Ratio (INR) 1,40, partial thromboplastin time (relation patient/control) were 1,50, albumin of 1,0 g/dl, urea of 99 mg/dl and creatinine of 3 mg/dl. HIV test and Ziehl Neelsen stain for acid-fast bacili were negative. Bronchoscopy showed no abnormalities. Aspergillus fumigatus was isolated by cultures of sputum and bronchoalveolar lavage. Immunodiffusion tests showed no Criptoccocus, Histoplasma or Aspergillus on blood. A pulmonary biopsy was not indicated because of his hypoproteinemia and coagulation disturb.
The chest radiograph revealed a thick-walled cavity in the right upper lobe with adjacent pleural thickening (Figure 1). The high-resolution computed tomography (HRCT) showed an irregular, thick-walled cavity in the right upper lobe and a mass with soft-tissue attenuation within it and thickening of adjacent pleura. Additional findings were bronchial wall thickening associated with a 'tree-in-bud' pattern, characterizing bronchiolitis, in the right upper, middle and lower lobes, and in the left lower lobe (Figure 2A and 2B). Along with this, a small bilateral pleural effusion was seen.
He received empirical treatment for tuberculosis during one month with no clinical response. Failure to respond to therapy and associating the radiologic, laboratory, and clinical findings a diagnostic of semi-invasive aspergillosis was made, so he was started on oral voriconazole 200 mg once every 12 hours. The patient responded well to the treatment with improvement in his systemic symptoms and regression of the pulmonary lesions (Figure 2C and 2D).