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A Case of Chronic Cavitary Pulmonary Aspergillosis Misdiagnose

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A Case of Chronic Cavitary Pulmonary Aspergillosis Misdiagnose Misled by significant peripheral eosinophilia and travel history: a case of chronic cavitary pulmonary Aspergillosis misdiagnosed as a ruptured Echinococcus cyst Whitney Elg-Salsman,DO; Anna Brady, MD Oregon Health & Science University [ ] Introduction Imaging Discussion Chronic cavitary pulmonary CT: LLL Aspergillosis can have a diverse cavitary AspergillosisDevelopment of(CPA) a New Practice is Model clinical presentation from non- lesion and characterized by cavitary new LLL invasive Allergic Pulmonary lesion(s), elevated IgG titers to ground glass Aspergillosis (ABPA), semi- Aspergillus +/- elevated total IgE opacities and invasive chronic cavitary consolidation and Aspergillus IgE. This case accompanied Aspergillosis to invasive. illustrates the importance of by a small Her clinical presentation has keeping Aspergillus infection on pleural aspects of both ABPA (allergic effusion the differential with significant asthma and total elevated IgE) pleural eosinophilia and cavitary and chronic, semi-invasive lung lesion cavitary Aspergillosis. Take Home Points Case Description [ ] References A 53-year-old non-smoking 1.1. [ ] Differential for pleural fluid woman with well controlled eosinophilia includes: allergic asthma presented to the infection (TB, fungal, hospital with three days of dyspnea parasite), malignancy, without infectious symptoms. She GMS stain: showing Aspergillus fungal HE stain: Thick fibrotic wall with a Eosinophilic granulomatosis reported prior travel including wild hyphae with uniform septated hyphae, dense eosinophilic exudate/infiltrate with polyangiitis, medications, and branching at 45° and Aspergillus sp hemothorax and animal exposure in Chile, Romania Hospital Course and recent mold/dust exposure due pneumothorax • Pulmonary and infectious disease were consulted to neighbor’s renovation. • Started Albendazole for empiric coverage of • Physical exam revealed 2. Keep Aspergillus on the Echinococcus crackles and diminished breath differential in the workup of a • Discharged 4 days later after pigtail drain was removed sounds at left base cavitary lung lesion especially • Re-presented with persistent non-productive cough • Labs: WBC 26 with with elevated IgE and • Labs: Eosinophilia 36%, and positive Aspergillus eosinophilia (42%), elevated IgE peripheral and pleural fumigatus IgE antibody, & negative Echinococcus IgG (2,000) eosinophilia • Bronchoscopy: Eosinophilia 80%, Charcot Leyden • Imaging: CT: crystals, negative fungal, AFB and Galactomannan hydropneumothorax with a left • ID started prednisone and ivermectin for Strongyloides lower lobe (LLL) cavitary lesion. coverage and praziquantel for coverage of alternate References •Thoracic surgery was consulted parasites including Paragonimus and placed a chest tube. Patterson, K.C. and M.E. Strek, • Due to persistent symptoms patient underwent left •Pleural fluid: consistent with Diagnosis and Treatment of lobectomy with cultures revealing Aspergillus fumigatus empyema and significant Pulmonary Aspergillosis • Patient was placed on 4 week course of Voriconazole to eosinophilia (84%) Syndromes. CHEST, 2014. help prevent pleural seeding with resolution of 146(5): p. 1358-1368. symptoms and peripheral eosinophilia.
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