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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 31  |  Issue : 2  |  Page : 94-96

Endobronchial aspergilloma mimicking bronchogenic carcinoma removed through flexible fiber-optic bronchoscopy


1 Department of Pulmonary Medicine, VPS Lakeshore Hospital, Kochi, Kerala, India
2 Department of Internal Medicine and Rheumatology, VPS Lakeshore Hospital, Kochi, Kerala, India
3 Department of Radiology, VPS Lakeshore Hospital, Kochi, Kerala, India
4 Department of Pathology, VPS Lakeshore Hospital, Kochi, Kerala, India

Date of Web Publication29-Sep-2017

Correspondence Address:
Muhammed Jasim Abdul Jalal
Department of Internal Medicine and Rheumatology, VPS Lakeshore Hospital, Nettoor P.O., Maradu, NH 47 Byepass, Kochi - 682 040, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijaai.ijaai_27_17

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  Abstract 


Endobronchial aspergilloma is a rare, noninvasive aspergillosis. It may be associated with a parenchymal lesion and/or cavity. We describe a case of endobronchial aspergillosis mimicking bronchogenic carcinoma subsequently removed completely through fiber-optic bronchoscope itself. This case report, while highlighting the existence of this unique clinical entity, also throws light on potential treatment option which can be curative.

Keywords: Aspergillosis, endobronchial aspergilloma, fiber-optic bronchoscopy


How to cite this article:
Lakshmanan P H, Abdul Jalal MJ, Jacob D, Emmanuel AM. Endobronchial aspergilloma mimicking bronchogenic carcinoma removed through flexible fiber-optic bronchoscopy. Indian J Allergy Asthma Immunol 2017;31:94-6

How to cite this URL:
Lakshmanan P H, Abdul Jalal MJ, Jacob D, Emmanuel AM. Endobronchial aspergilloma mimicking bronchogenic carcinoma removed through flexible fiber-optic bronchoscopy. Indian J Allergy Asthma Immunol [serial online] 2017 [cited 2019 Sep 17];31:94-6. Available from: http://www.ijaai.in/text.asp?2017/31/2/94/215835




  Introduction Top


Endobronchial aspergilloma is a noninvasive form of aspergillosis. It is characterized by massive intrabronchial overgrowth of the aspergillus species, mainly aspergillus fumigates. It may be associated with a parenchymal lesion and/or cavity. We report a case of 57-year-old male patient with a history of chronic cough who was diagnosed to have endobronchial aspergillosis and was subsequently removed completely through fiberoptic bronchoscope itself.


  Case Report Top


A 57-year-old male, nonsmoker, asthmatic, diabetic, and hypertensive, presented with the complaints of a cough and wheeze of 6 months. He was taking on and off medications for wheeze with no prior hospitalization. On examination, he was hemodynamically stable with an arterial blood pressure of 130/70 mmHg, heart rate of 78/min, respiratory rate of 18/min, and temperature of 37.6°C. On chest auscultation, air entry was bilaterally equal with a bilateral wheeze. Examination of other systems was noncontributory.

Laboratory findings were as follows: White blood cell count: 10,600/mm 3, erythrocyte sedimentation rate: 50 mm/h, and total IgE: 3.11 IU/ml. Eosinophil count was normal. Spirometry values were in normal range. The patient's initial chest X-ray showed right lower zone linear band-like opacity. HIV serology was negative.

A computerized tomography of the thorax revealed middle lobe bronchiectasis with intraluminal lesion-lobulated soft tissue mass in right bronchus [Figure 1].
Figure 1: (a) Coronal computerized tomography chest showing lobulated soft tissue mass in right bronchus. (b) Axial computerized tomography chest showing lobulated soft tissue mass in right bronchus

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Diagnostic fiber-optic bronchoscopy was performed. An irregular fleshy intraluminal mass obstructing the right bronchus intermedius was seen. Histopathology of the endobronchial lesion was consistent with aspergilloma [Figure 2]a,[Figure 2]b,[Figure 2]c.
Figure 2: (a) Mass of slender hyphae of Aspergillus (H and E stain, ×400). (b) Mass of slender hyphae of Aspergillus (PAS stain, ×400). (c) Mass of slender hyphae of Aspergillus (GMS- stain, ×400)

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The patient was treated with itraconazole 100 mg twice a day and tapering dose of oral steroids for 8 weeks. Even though he reported a slight improvement in respiratory symptoms, chest signs persisted. Repeat bronchoscopy after 8 weeks of medical treatment revealed the persistence of the intraluminal lesion [Figure 3]a. Hence, the same was removed in piecemeal using biopsy forceps and giving good saline lavage ultimately achieving complete clearance and luminal patency [Figure 3]b. The distal orifices were inspected which were found to be normal. Subsequently, he was discharged on inhaled medications (inhaled corticosteroids and long-acting beta-agonists). Follow up after 1 month revealed significant improvement in respiratory symptoms and signs. Repeat bronchoscopy showed no recurrence. The patient is maintained on inhaled medications with periodic follow up.
Figure 3: (a) Bronchoscopy showing fleshy necrotic mass occluding bronchus intermedius. (b) Bronchoscopy showing restored patency of bronchus intermedius after piecemeal removal and saline lavage

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  Discussion Top


In 1952, Hinson et al. categorized pulmonary aspergillosis based on host immunity, into invasive aspergillosis, allergic bronchopulomonary aspergillosis (ABPA) and aspergilloma.[1] In 1981, Gefter et al. described a fourth entity characterized by limited invasion of lung parenchyma– termed as “semi-invasive aspergillosis, an intermediate form in between invasive aspergillosis and aspergilloma.”[2] In 1969, Sawasaki et al. described bronchial stump aspergillosis, a lung resection sequelae caused by secondary infection of the silk suture material used to close the bronchus.[3]

Endobronchial aspergilloma is rare and does not fit into any of the above-mentioned categories. It is usually detected incidentally as a necrotic mass causing bronchial obstruction. In 1991, Denning et al. first described endobronchial aspergilloma in three patients with AIDS.[4],[5]

Air flow stasis to colonize the bronchial lumen is essential for endobronchial aspergilloma. Hence, a nidus or structural change that induces air flow stasis is a predisposing factor for aspergillosis in immunocompetent individuals. The patients may have an underlying lung disease such as asthma, chronic bronchitis, or cystic fibrosis. Endobronchial aspergilloma is usually asymptomatic. However, it can also present with a cough and hemoptysis.

Endobronchial aspergilloma sometimes mimic an endobronchial lung cancer.[6] A superimposed endobronchial aspergilloma can mask an endobronchial carcinoid or a lung cancer.[7] It can be often associated with a foreign body [8] and can cause a bronchomediastinal fistula.[9]

Endobronchial aspergilloma may be a sole manifestation of pulmonary aspergillosis. It can also be associated with pulmonary aspergillosis including chronic necrotizing pulmonary aspergillosis or ABPA.[10] The approach to endobronchial aspergilloma includes bronchoscopic biopsy followed by histopathology examination.

Endobronchial aspergilloma may be a simple colonization of airway lumen of aspergillus species in the immune-competent host and hence does not require any specific treatment. Anti-fungal therapy has usually no benefit. Surgical resection may be considered as an alternative treatment strategy in patients with a favorable pulmonary reserve.[11],[12]

In conclusion, endobronchial aspergilloma is usually an incidental finding. It can mimic an endobronchial malignancy. It usually occurs in immunocompromised individuals and in patients with underlying lung disease but can also occur otherwise. It is a necrotic mass obstructing bronchus. Bronchoscopy is the tool for diagnosis and can be confirmed by biopsy. This case is more than just a bronchoscopic curiosity, as it helps us to understand the wide variety of pulmonary aspergillosis. Optimal treatment strategy has not yet been established.

We describe a rare entity (endobronchial aspergillosis) mimicking a common medical condition (bronchogenic carcinoma). Complete removal of this intrabronchial lesion through flexible fiber-optic bronchoscopy and mild sedation obviating the need for more invasive procedures such as rigid bronchoscopy and general anesthesia makes our case more interesting. This case report, while highlighting the existence of this unique clinical entity, also throws light on potential treatment option which can be curative.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hinson KF, Moon AJ, Plummer NS. Broncho-pulmonary aspergillosis; a review and a report of eight new cases. Thorax 1952;7:317-33.  Back to cited text no. 1
    
2.
Gefter WB, Weingrad TR, Epstein DM, Ochs RH, Miller WT. “Semi-invasive” pulmonary aspergillosis: A new look at the spectrum of Aspergillus infections of the lung. Radiology 1981;140:313-21.  Back to cited text no. 2
    
3.
Sawasaki H, Horie K, Yamada M, Tajima G, Katsura S, Naito Y, et al. Bronchial stump aspergillosis. Experimental and clinical study. J Thorac Cardiovasc Surg 1969;58:198-208.  Back to cited text no. 3
    
4.
Denning DW, Follansbee SE, Scolaro M, Norris S, Edelstein H, Stevens DA. Pulmonary aspergillosis in the acquired immunodeficiency syndrome. N Engl J Med 1991;324:654-62.  Back to cited text no. 4
    
5.
Araújo D, Figueiredo M, Monteiro P. Endobronchial aspergilloma: An unusual presentation of pulmonary aspergillosis. Rev Port Pneumol 2016;22:61-2.  Back to cited text no. 5
    
6.
Ermis H, Çelik MR, Gulbas G, Tavli D, Aytemur ZA, Aydın NE. Mucoid impaction of bronchi with Aspergillus (A case mimicking lung cancer). Afr J Microbiol Res 2012;6:7335-8.  Back to cited text no. 6
    
7.
Nilsson JR, Restrepo CS, Jagirdar J. Two cases of endobronchial carcinoid masked by superimposed aspergillosis: A review of the literature of primary lung cancers associated with Aspergillus. Ann Diagn Pathol 2013;17:131-6.  Back to cited text no. 7
    
8.
Jung SW, Kim MW, Cho SK, Kim HU, Lee DC, Yoon BK, et al. Acase of endobronchial aspergilloma associated with foreign body in immunocompetent patient without underlying lung disease. Tuberc Respir Dis (Seoul) 2013;74:231-4.  Back to cited text no. 8
    
9.
Argento AC, Wolfe CR, Wahidi MM, Shofer SL, Mahmood K. Bronchomediastinal fistula caused by endobronchial aspergilloma. Ann Am Thorac Soc 2015;12:91-5.  Back to cited text no. 9
    
10.
Dobbertin I, Friedel G, Jaki R, Michl M, Kimmich M, Hofmann A, et al. Bronchial aspergillosis. Pneumologie 2010;64:171-83.  Back to cited text no. 10
    
11.
Sagan D, Gozdziuk K. Surgery for pulmonary aspergilloma in immunocompetent patients: No benefit from adjuvant antifungal pharmacotherapy. Ann Thorac Surg 2010;89:1603-10.  Back to cited text no. 11
    
12.
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.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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