|Year : 2016 | Volume
| Issue : 2 | Page : 99-101
Allergic bronchopulmonary aspergillosis mimicking lung cancer in a nonasthmatic male patient
Arun Kannan, Sowmya Gopalan, Preetam Arthur
General Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India
|Date of Web Publication||5-Dec-2016|
Sri Ramachandra Medical College and Research Institute, Porur, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Presentation of Aspergillus infections of the lung is varied. Allergic bronchopulmonary aspergillosis (ABPA) is one such presentation in which there is hypersensitivity reaction to Aspergillus antigens. It occurs commonly in asthmatics and patients with cystic fibrosis. We report a case of ABPA in a 55-year-old male initially evaluated for left lung cancer who had never been diagnosed with asthma.
Keywords: Allergic bronchopulmonary aspergillosis, asthma, lung cancer
|How to cite this article:|
Kannan A, Gopalan S, Arthur P. Allergic bronchopulmonary aspergillosis mimicking lung cancer in a nonasthmatic male patient. Indian J Allergy Asthma Immunol 2016;30:99-101
|How to cite this URL:|
Kannan A, Gopalan S, Arthur P. Allergic bronchopulmonary aspergillosis mimicking lung cancer in a nonasthmatic male patient. Indian J Allergy Asthma Immunol [serial online] 2016 [cited 2019 Jul 17];30:99-101. Available from: http://www.ijaai.in/text.asp?2016/30/2/99/195264
| Introduction|| |
Pulmonary diseases caused by Aspergillus species are of many types such as aspergilloma (fungal ball), allergic bronchopulmonary aspergillosis (ABPA) (allergic type), invasive pulmonary aspergillosis (invasive type), and chronic necrotizing pulmonary aspergillosis (semi-invasive type), based on the host immunity and the virulence of the organism.  ABPA is an allergic disorder which was first reported in 1952 by Hinson et al.  It is usually seen in patients with bronchial asthma and cystic fibrosis. De novo presentation of ABPA is rare and often mistaken for other pulmonary diseases resulting in delay in diagnosis and initiation of therapy. We report a case of ABPA in a patient who had no pre-existing lung disease.
| Case Report|| |
A 55-year-old male, nonsmoker, with no previous comorbidities, was referred to our institution as a suspected case of lung cancer. He had been having cough with mucoid expectoration for about a month prior to admission and had taken oral antibiotics and antihistaminics for the same. He also complained of breathlessness and weight loss of 4 kg. He had no hemoptysis or fever. He had had a chest X-ray taken at an outside hospital which had shown a left mid-zone nonhomogeneous opacity and hence had been referred as lung cancer. At admission, his general condition was good. Auscultation of his chest revealed few crepitation in the left mammary area.
Blood investigations revealed a total white blood cell count of 10,900 with eosinophils of 18.8% and absolute eosinophil count of 1626 and IgE level being 1480 IU/ml. Chest X-ray showed a left mid-zone nonhomogeneous opacity [Figure 1]. Computed tomography (CT) thorax was done which revealed symmetrical focal central bronchiectasis with surrounding patch of consolidation involving part of upper and middle lobes [Figure 2]. Based on this, a suspicion of ABPA was raised. Microbiological analysis of the sputum revealed Aspergillus fumigatus colonies. Serological test was positive for Aspergillus antibodies. Aspergellin skin test was positive. With these, we came to a diagnosis of ABPA and ruled out lung cancer (six out of eight in Rosenberg-Patterson criteria).
|Figure 2: Computed tomography thorax with central bronchiectasis and surrounding consolidation|
Click here to view
The patient was treated with oral prednisolone 0.5 mg/kg/day which was gradually tapered and with itraconazole 400 mg twice daily for 3 days followed by 200 mg twice a day for 16 weeks. Clearance of the radiological opacity and reduction in IgE levels were observed during follow-up.
| Discussion|| |
Aspergillosis is a common term used to denote all disease entities caused by nearly fifty pathogenic species of Aspergillus. Of these, A. fumigatus accounts for most cases of invasive and allergic aspergillosis. The required size of inoculum to cause infection is uncertain, but in general, an intense exposure is required to cause disease in an immunocompetent person.
ABPA represents a Type 1 and 3 hypersensitivity reaction to A. fumigatus commonly. ABPA occurs in nearly 1%-2% of patients with persistent asthma and in 2%-15% of adults with cystic fibrosis.  Episodes of bronchial obstruction with mucous plugs leading to coughing fits, pneumonia, consolidation, and breathlessness are typical. There are five stages of disease process: Stage I (acute), Stage II (remission), Stage III (exacerbation), Stage IV (steroid dependent), and Stage V (fibrotic).  The disease may have periods of remission and exacerbation and may later progress on to cause interstitial fibrosis.
A diagnostic criterion described by Rosenberg and Patterson has been used in diagnosing ABPA which includes eight major criteria including clinical (bronchial asthma), laboratory (eosinophilia, serum-precipitating antibodies, elevated IgE levels >1000 IU/ml, and Serum A. fumigatus specific antibodies), radiological (fleeting opacities on chest X-ray and central bronchiectasis on CT scan), and positive skin test for Aspergillus antigen. 
The diagnosis of ABPA may be confirmed if at least six major criteria are met, although it is also acceptable to confirm the diagnosis based on minimum criteria.
Chest X-ray findings in ABPA are variable, the most common being transient pulmonary infiltrates, atelectasis, and bronchiectasis. Less commonly, there may be cavities and fibrosis. 
ABPA without bronchial asthma is rare, and <50 cases have been reported worldwide mostly to A. fumigatus but one to Aspergillus niger.  It was mistaken for other entities such as tuberculosis and bronchogenic carcinoma in almost all of these cases. ,
Using glucocorticoids at a dose of 0.5 mg/kg/day is the treatment of choice for ABPA. Treatment is usually for 6 months, but it can be prolonged to 12 months also. Addition of an antifungal, preferably itraconazole, still requires further studies but was given for our patient since sputum grew colonies of Aspergillus. Steven et al. had done a double-blind, randomized controlled study on the effectiveness of itraconazole in ABPA, which showed that 45% improved with the addition of itraconazole 200 mg twice a day for 12 weeks.  Efficiency of the treatment is monitored by lowering serum IgE levels and clearing pulmonary opacities in chest X-ray. Ideally, patients must undergo an evaluation for every 6-8 weeks in the 1 st year followed by every 6-12 months. 
| Conclusion|| |
ABPA is an underdiagnosed condition that may present with varied clinical and radiological presentations. When a patient does not respond to antibiotics or evaluation is not suggestive of malignancy, ABPA must be a differential diagnosis that is to be considered, and appropriate treatment must be initiated.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Soubani AO, Chandrasekar PH. The clinical spectrum of pulmonary aspergillosis. Chest 2002;121:1988-99.
Hinson KF, Moon AJ, Plummer NS. Broncho-pulmonary aspergillosis; a review and a report of eight new cases. Thorax 1952;7:317-33.
Greenberger PA. Clinical aspects of allergic bronchopulmonary aspergillosis. Front Biosci 2003;8:s119-27.
Patterson R, Greenberger PA, Radin RC, Roberts M. Allergic bronchopulmonary aspergillosis: Staging as an aid to management. Ann Intern Med 1982;96:286-91.
Rosenberg M, Patterson R, Mintzer R, Cooper BJ, Roberts M, Harris KE. Clinical and immunologic criteria for the diagnosis of allergic bronchopulmonary aspergillosis. Ann Intern Med 1977;86:405-14.
Shah A, Panchal N, Agarwal AK. ABPA - The spectrum of roentgenologic appearances. Indian J Radiol Imaging 1999;9:107-12.
Shah A, Maurya V, Panjabi C, Khanna P. Allergic bronchopulmonary aspergillosis without clinical asthma caused by Aspergillus niger
. Allergy 2004;59:236-7.
Agarwal R, Aggarwal AN, Gupta D, Bal A, Das A. Case report: A rare cause of miliary nodules - Allergic bronchopulmonary aspergillosis. Br J Radiol 2009;82:e151-4.
Nowicka U, Wiatr E, Jakubowska L, Polubiec-Kownacka M. A case report: ABPA mimicking lung cancer in a non asthmatic female. Pneumonol Alergol Pol 2012;80:77-8.
Stevens DA, Schwartz HJ, Lee JY, Moskovitz BL, Jerome DC, Catanzaro A, et al
. A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis. N Engl J Med 2000;342:756-62.
[Figure 1], [Figure 2]