Aspergillosis Presenting as Bilateral Pleural Effusion
Aspergillosis Presenting as Bilateral Pleural Effusion
Our patient, a 64-year-old woman who was a non-smoker with a background history of epilepsy, presented to our respiratory clinic in May 2008 with a six-month history of productive cough with whitish sputum associated with three episodes of hemoptysis. She had no constitutional symptoms. At a primary care clinic a diagnosis of tuberculosis (TB) was considered, but the results of a Mantoux test were negative and findings from the three sputum acid-fast bacilli samples and cultures for TB were also negative. Her symptoms were persistent despite a few courses with oral antibiotics such as oral amoxicillin, azithromycin and moxifloxacin. On examination, our patient was emaciated (body mass index of 19.3 kg/m), hemodynamically stable, apyretic, eupneic and with peripheral oxygen saturation (SpO2) of 98% (FiO2 21%). She did not have clubbed fingers, palpable cervical lymph nodes or oral thrush.
A bacillus Calmette-Guérin (BCG) scar was present. Her jugular venous pressure was not elevated, and her apex beat was not displaced. An examination of her respiratory system revealed reduced breath sounds at the bases. Based on our patient's history and the physical examination, the differential diagnoses were bronchogenic carcinoma, pulmonary tuberculosis and bronchiectasis.
The results of initial investigations showed a normocytic normochromic anemia (hemoglobin level of 10.3 g/dL) with normal white cell and platelet counts. Her inflammatory markers were raised: her CRP was 3.24 mmol/L and ESR was 66 mm/hour. Other blood investigations were normal. An initial chest radiograph showed bilateral pleural effusion with bibasal consolidation (Figure 1). A thoracocentesis procedure was not performed as the pleural effusion looked minimal. Subsequently, bronchoscopy was performed, showing an edematous and white coated bronchial tree mucosa; the right lower lobe mucosa had an infiltrate appearance. The mycological bronchoalveolar lavage culture tested positive for Aspergillus niger. The mycobacterial cultures tested negative. Unfortunately, a transbronchial biopsy was not performed in the same setting.
(Enlarge Image)
Figure 1.
Pre-treatment and post-treatment chest radiographs. After two months of antifungal therapy, there was complete resolution of the bilateral pleural effusion with significant improvement in the bibasal consolidation.
Fulfilling the proposed diagnostic criteria by Soubani et al., a diagnosis of chronic necrotizing pulmonary aspergillosis was made based on the subacute presentation of six months' duration and microbiological culture that grew A. niger. Our patient was discharged with itraconazole 200 mg (syrup) to be taken once daily for an estimated duration of six months. The syrup form was chosen instead of the capsule form for better absorption. After two months of treatment, clinical and radiological improvements were noted on follow-up tests. The itraconazole syrup was continued, aiming for a minimum treatment duration of six months.
Case Presentation
Our patient, a 64-year-old woman who was a non-smoker with a background history of epilepsy, presented to our respiratory clinic in May 2008 with a six-month history of productive cough with whitish sputum associated with three episodes of hemoptysis. She had no constitutional symptoms. At a primary care clinic a diagnosis of tuberculosis (TB) was considered, but the results of a Mantoux test were negative and findings from the three sputum acid-fast bacilli samples and cultures for TB were also negative. Her symptoms were persistent despite a few courses with oral antibiotics such as oral amoxicillin, azithromycin and moxifloxacin. On examination, our patient was emaciated (body mass index of 19.3 kg/m), hemodynamically stable, apyretic, eupneic and with peripheral oxygen saturation (SpO2) of 98% (FiO2 21%). She did not have clubbed fingers, palpable cervical lymph nodes or oral thrush.
A bacillus Calmette-Guérin (BCG) scar was present. Her jugular venous pressure was not elevated, and her apex beat was not displaced. An examination of her respiratory system revealed reduced breath sounds at the bases. Based on our patient's history and the physical examination, the differential diagnoses were bronchogenic carcinoma, pulmonary tuberculosis and bronchiectasis.
The results of initial investigations showed a normocytic normochromic anemia (hemoglobin level of 10.3 g/dL) with normal white cell and platelet counts. Her inflammatory markers were raised: her CRP was 3.24 mmol/L and ESR was 66 mm/hour. Other blood investigations were normal. An initial chest radiograph showed bilateral pleural effusion with bibasal consolidation (Figure 1). A thoracocentesis procedure was not performed as the pleural effusion looked minimal. Subsequently, bronchoscopy was performed, showing an edematous and white coated bronchial tree mucosa; the right lower lobe mucosa had an infiltrate appearance. The mycological bronchoalveolar lavage culture tested positive for Aspergillus niger. The mycobacterial cultures tested negative. Unfortunately, a transbronchial biopsy was not performed in the same setting.
(Enlarge Image)
Figure 1.
Pre-treatment and post-treatment chest radiographs. After two months of antifungal therapy, there was complete resolution of the bilateral pleural effusion with significant improvement in the bibasal consolidation.
Fulfilling the proposed diagnostic criteria by Soubani et al., a diagnosis of chronic necrotizing pulmonary aspergillosis was made based on the subacute presentation of six months' duration and microbiological culture that grew A. niger. Our patient was discharged with itraconazole 200 mg (syrup) to be taken once daily for an estimated duration of six months. The syrup form was chosen instead of the capsule form for better absorption. After two months of treatment, clinical and radiological improvements were noted on follow-up tests. The itraconazole syrup was continued, aiming for a minimum treatment duration of six months.