|Year : 2016 | Volume
| Issue : 1 | Page : 32-34
Complex aspergilloma presenting as chronic dry cough: An unusual finding
Shubhra Jain, Aashish Kumar Singh, Vinod Joshi
Department of Respiratory Medicine, Institute of Respiratory Diseases, SMS Medical College, Jaipur, Rajasthan, India
|Date of Web Publication||2-Aug-2016|
Aashish Kumar Singh
A13 B, Ram Marg, Vijay Path, Tilak Nagar, Jaipur - 302 004, Rajasthan
Source of Support: None, Conflict of Interest: None
The most common symptom of aspergilloma is hemoptysis. Dry cough is a rare symptom of aspergilloma. It is estimated that 10-20% of tubercular-healed cavities are colonized by fungus. The case report discusses persistent dry cough in a 30-year-old male. Radiograph of the chest revealed left upper zone infiltrates while contrast-enhanced computed tomography of the chest revealed classical Monad sign suggestive of aspergilloma. Diagnosis was confirmed by anti-Aspergillus antibodies (100 IU/ml) and growth of Aspergillus fumigatus in sputum fungal culture.
Keywords: Aspergilloma, Aspergillus fumigatus, dry cough, Monad sign
|How to cite this article:|
Jain S, Singh AK, Joshi V. Complex aspergilloma presenting as chronic dry cough: An unusual finding. Indian J Allergy Asthma Immunol 2016;30:32-4
|How to cite this URL:|
Jain S, Singh AK, Joshi V. Complex aspergilloma presenting as chronic dry cough: An unusual finding. Indian J Allergy Asthma Immunol [serial online] 2016 [cited 2020 Jul 15];30:32-4. Available from: http://www.ijaai.in/text.asp?2016/30/1/32/187566
| Introduction|| |
Common causes of dry cough are bronchial asthma, gastroesophageal reflux disease, and postnasal drip. Diagnostic criteria of pulmonary aspergilloma range from classical radiological sign of an intracavitary mass with a surrounding crescent of air and either positive Aspergillus precipitin test, positive sputum culture for Aspergillus, or (in most cases) both. Despite several published series from various parts of the country, this disease is still underrecognized and misdiagnosed as pulmonary tuberculosis. This has serious clinical implications as these patients often receive antitubercular treatment for a long time while lung damage continues to progress relentlessly.  Here, we present a case of complex aspergilloma in a treated pulmonary tuberculosis patient causing chronic dry cough.
| Case report|| |
A 30-year-old nonsmoker male presented with dry and distressing cough for 5 years. There was no postural, seasonal, or diurnal variation in cough. The patient denied any history of fever, chest pain, expectoration, hemoptysis, or breathlessness. He was a farmer with no history of substance abuse. The patient had history of antitubercular treatment twice, which were DOTS CAT I (8 years back) and DOTS CAT II (5 years back). Prior to reporting us, the patient received off and on inhaled salbutamol and beclomethasone without any relief. His blood pressure was 130/80 mmHg, heart rate 100 beats/min, and respiratory rate 16/min. Respiratory system examination revealed no significant finding. Routine blood investigations such as blood glucose, complete blood count, and renal and liver function tests were within normal limits. HIV was nonreactive. After induction with 3% hypertonic saline, sputum smear was negative for acid-fast bacilli (AFB). Spirometer parameters were within normal limits. Radiograph of the chest posteroanterior view revealed patchy infiltrates in the left upper zone [Figure 1] while contrast-enhanced computed tomography (CECT) of the chest revealed aspergilloma in the left upper lobe cavity [Figure 2]. IgG antibody to Aspergillus titer was 100 IU/ml. Fiberoptic bronchoscopy was performed and bronchial washings were sent for AFB culture by BACTEC, Gram staining, pyogenic culture, and fungal culture. The investigations revealed no growth of Mycobacterium tuberculosis after 6 weeks; Gram staining and pyogenic culture were sterile, and fungal culture revealed growth of Aspergillus fumigatus. Hence, the case was diagnosed as complex aspergilloma. The patient was prescribed oral itraconazole 200 mg twice a day and had improvement in his dry cough after 2 months of treatment. After 6 months of treatment, there was marked improvement in dry cough. Repeat IgG antibody to Aspergillus titer was 50 IU/ml. His repeat chest radiograph was the same as before initiation of treatment while repeat CECT of the chest revealed marginal improvement [Figure 3].
|Figure 2: Computed tomography of the chest showing classical "air meniscus" sign in upper lobe|
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|Figure 3: Contrast-enhanced computed tomography after 6 months treatment showing marginal improvement in fungal ball|
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| Discussion|| |
Aspergillus is a common fungus that grows on dead leaves, stored grain, bird droppings, and compost piles. A. fumigatus is the most common species in over 90% of cases. ,, The other commonly recovered species are Aspergillus flavus, Aspergillus niger, and Aspergillus terreus although Mucor species occasionally were implicated. The overall incidence of aspergilloma in general population has been estimated to be 0.01% in Great Britain and 0.017% in the USA. 
The formation of pulmonary intracavitary fungal ball (aspergilloma) results from colonization of a preformed or natural airspace. It occurs in 10-20% of tuberculous-healed cavities. Less frequently, it ensues in lung cavities resulting from necrotizing infection, bronchiectasis, bronchial cysts, emphysema bullae, sarcoidosis, and lung cancer with cavitation. Lesion itself consists of a tangled mass of fungal hyphae, fibrin, epithelial cells, mucus, debris, and blood cells. It can also appear in the brain, kidney, or other organs.
Pulmonary aspergilloma can be classified into simple and complex. The simple form presents as an isolated cavity with thin walls, surrounded by normal lung parenchyma. More common is the complex form, where cavities have thick walls surrounded by fibrotic lung tissue, stiff hilar structures, vascular adhesions, and obliteration of the pleural cavity. The changes are observed more frequently in sequelae of pulmonary tuberculosis.  The most common clinical manifestation of fungal ball is hemoptysis. Other signs and symptoms include chronic cough, expectoration, dyspnea, clubbing, asthenia, and weight loss.  The typical radiographic appearance of aspergilloma is a bell-like image with fungus ball appearing as a clapper inside the bell. A semi-circular, crescentic air shadow appears around the radiopaque fungus ball located in the upper lobe lung cavity (air crescent sign). The fungus ball changes its position as the patient moves.  Occasionally, the mass may entirely fill the cavity, obliterating the surrounding air crescent and no longer being mobile. The radiological differential diagnosis includes organized hematoma or pus inside the cavity, neoplasm, and hydatid cyst.
CT scan is more accurate technique in defining fungus balls, particularly in fibrotic and distorted lung fields. Sputum culture may confirm the presence of fungus but may be negative in some cases. The serum precipitins against Aspergillus species are positive in almost all patients. Skin testing is less helpful. On bronchoscopy, the fungus ball may be visualized in direct continuity with the bronchial lumen. Bronchial washings, brushing, and forceps biopsy may be carried out to isolate the fungus.
Treatment of aspergilloma is controversial. Regarding medical treatment, a lot of regimens are available, including amphotericin B, sodium or potassium iodide, itraconazole, and fluconazole. Itraconazole is an orally active triazole antifungal agent with less toxicity, high tissue penetration, and greater in vitro activity against A. fumigatus than amphotericin B. Effective dose of itraconazole is usually 200-400 mg/day orally with a duration of treatment of 6-18 months.  Itraconazole or amphotericin B can be injected inside the mycetoma percutaneously under CT guidance if response to oral medications is not adequate.  Systemic antifungal therapy using intravenous amphotericin B has no effect.  Definitive treatment of aspergilloma is surgical resection but with a high morbidity and mortality (7-25%).  Surgical resection is restricted to patients with severe hemoptysis and adequate pulmonary function and patients with poor prognosis.  Major postoperative complications include hemorrhage, residual pleural space, bronchopleural fistula, empyema, and respiratory failure.
Natural history of aspergilloma varies from a stable lesion to progression and even spontaneous regression is reported in about 5% cases. Mortality due to aspergilloma is reported at a rate of 6% per annum.
In our case, the patient did not have hemoptysis and chest radiograph also showed patchy infiltrates. CT scan helped to diagnose aspergilloma which was further confirmed by fungal culture and anti-Aspergillus antibodies. The patient was treated with oral itraconazole 400 mg/day to which he responded.
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| References|| |
Rafferty P, Biggs BA, Crompton GK, Grant IW. What happens to patients with pulmonary aspergilloma? Analysis of 23 cases. Thorax 1983;38:579-83.
Lee JG, Lee CY, Park IK, Kim DJ, Chang J, Kim SK, et al.
Pulmonary aspergilloma: Analysis of prognosis in relation to symptoms and treatment. J Thorac Cardiovasc Surg 2009;138:820-5.
Akbari JG, Varma PK, Neema PK, Menon MU, Neelakandhan KS. Clinical profile and surgical outcome for pulmonary aspergilloma: A single center experience. Ann Thorac Surg 2005;80:1067-72.
Kim YT, Kang MC, Sung SW, Kim JH. Good long-term outcomes after surgical treatment of simple and complex pulmonary aspergilloma. Ann Thorac Surg 2005;79:294-8.
British Thoracic and Tuberculosis Association. Aspergilloma and residual tuberculous cavities - The results of a resurvey. Tubercle 1970;51:227-45.
Regnard JF, Icard P, Nicolosi M, Spagiarri L, Magdeleinat P, Jauffret B, et al.
Aspergilloma: A series of 89 surgical cases. Ann Thorac Surg 2000;69:898-903.
Osinowo O, Softah AL, Zahrani K, Zaharani ME, Al-Mosallami IA. Pulmonary aspergilloma simulating bronchogenic carcinoma. Indian J Chest Dis Allied Sci 2003;45:59-62.
Roberts CM, Citron KM, Strickland B. Intrathoracic aspergilloma: Role of CT in diagnosis and treatment. Radiology 1987;165:123-8.
Gupta PR, Jain S, Kewlani JP. A comparative study of itraconazole in various dose schedules in the treatment of pulmonary aspergilloma in treated patients of pulmonary tuberculosis. Lung India 2015;32:342-6.
Klein JS, Fang K, Chang MC. Percutaneous transcatheter treatment of an intracavitary aspergilloma. Cardiovasc Intervent Radiol 1993;16:321-4.
Hammerman KJ, Sarosi GA, Tosh FE. Amphotericin B in the treatment of saprophytic forms of pulmonary aspergillosis. Am Rev Respir Dis 1974;109:57-62.
Cheng WH, Shih CL, Jen CC, Hong WG, Yeung LC. Complex pulmonary aspergilloma: A case report. J Med Sci 2001;21:301-4.
Jewkes J, Kay PH, Paneth M, Citron KM. Pulmonary aspergilloma: Analysis of prognosis in relation to haemoptysis and survey of treatment. Thorax 1983;38:572-8.
[Figure 1], [Figure 2], [Figure 3]