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: first published as 10.1136/thx.44.8.676 on 1 August 1989. Downloaded from Thorax 1989;44:676-677

Postirradiation complicated by aspergilloma and bronchocentric granulomatosis H MAKKER, K McCONNOCHIE, A R GIBBS From the Department of and Chest Diseases and Department of Pathology, University of Wales College ofMedicine, Llandough Hospital, Penarth, South Glamorgan

ABSTRACT An asthmatic patient requiring cortico- showed an aspergilloma in the right upper lobe, steroid treatment developed a pulmonary asper- extensive , and interstitial fibrosis in gilloma in an area of postmastectomy radiation the middle and lower lobes, interpreted as radiation . fibrosis. At necropsy bronchocentric granulomatosis In the middle and lower lobes several small bronchi and was also found. bronchioles showed eosinophilic necrosis with granulo- matous changes in their walls-that is, the changes of The major clinical syndromes associated with Aspergillus bronchocentric granulomatosis (figure); direct staining dis- fumigatus are allergic (, allergic bronchopulmonary closed small numbers of aspergillus hyphae. The left aspergillosis, and extrinsic allergic alveolitis), saprophytic showed and small focal areas of inter- (mycetoma), and invasive. It is uncommon for these different stitial fibrosis; the bronchi showed basement membrane forms to occur in the same patient. thickening and muscular hypertrophy but no other asthmatic features. Case report

A 52 year old woman, a non-smoker, with atopic asthma Discussion copyright. since childhood and mild , had an excision of the right breast in June 1986, which This patient's asthma, which began in childhood, may have revealed adenocarcinoma. She received a course of radio- been a manifestation of allergic bronchopulmonary asper- therapy. In December 1986 she complained of pleurisy and gillosis, though none of the features of this disorder was her showed a right upper zone opacity. The documented before her radiotherapy. Aspergilloma has been results ofinvestigations, which included bronchoscopy, were reported in postirradiation pulmonary fibrosis"2 and possibly http://thorax.bmj.com/ normal except for a raised serum IgE concentration and both irradiation and allergic bronchopulmonary asper- aspergillus precipitins. She responded to prednisolone and gillosis predisposed to its development in this case. was well until October 1987, when she again presented with Bronchocentric granulomatosis may be a manifestation of pleurisy associated with and purulent . On this allergic bronchopulmonary aspergillosis,3 presumably owing occasion A fwnigatus was isolated from her sputum, to an immunological reaction to the aspergillus, but may precipitins were present, and serum IgE exceeded 1000 ng/l. occur in non-atopic individuals, when the pathogenesis is Her chest radiograph now showed an ill defined right upper unknown. In this case it is likely to have been a consequence zone opacity with contraction and distortion. Two weeks of allergic bronchopulmonary aspergillosis as aspergillus later there was evidence of a cavity and tomography sugges- hyphae were found in the lesions. Bronchocentric ted the presence of a mycetoma. Her condition deteriorated granulomatosis is uncommon and to the best of our on September 27, 2021 by guest. Protected despite prednisolone and she required frequent courses of knowledge has not been described in association with antibiotics. In January 1988 she developed an , aspergilloma, though aspergilloma may follow allergic bron- from which she died. chopulmonary aspergillosisW7 and vice versa.8 At necropsy there was bilateral pleural thickening with The changes of bronchocentric granulomatosis were dense adhesions. The right upper lobe ofthe lung was almost present in the middle and lower lobes ofthe right lung despite completely destroyed by a large irregular cavity, containing treatment, whereas active allergic bronchopul- brown friable material, which communicated with thepleural monary aspergillosis was not present in the left lung. The cavity. The middle and lower lobes were solid apart from change on the right might have resulted from continual three small cavities in the apical segment. The left lung leakage of aspergillus from the right upper lobe into the showed multiple foci of bronchopneumonia but no other middle and lower lobe bronchi. macroscopic abnormality. Microscopic examination of the In the absence of massive haemoptysis medical man- agement of aspergilloma is usually appropriate. In this case there was no response to corticosteroid treatment, which may Address for reprint requests: Dr K McConnochie, Department of to infection. Tuberculosis and Chest Disease, Llandough Hospital, Penarth, South have been detrimental by lowering resistance Glamorgan CF6 IXX. Ketoconazole was also ineffective. Surgery might have been useful, if only to remove the source of antigenic stimulus, Accepted 9 May 1989 and-given the fatal outcome-we would recommend that in 676 Thorax: first published as 10.1136/thx.44.8.676 on 1 August 1989. Downloaded from Postirradiation pulmonaryfibrosis complicated by aspergilloma and bronchocentric granulomatosis 677

Lung tissue showing substantialfibrosis (F) with an area of granulomatous containing giant cells (arrowed) centered on a bronchiole (B).

these circumstances consideration should be given to this 4 Henderson AH. Allergic aspergillosis: review of 32 cases. Thorax approach. 1968;23:501-12. 5 Safirstein BH. Aspergilloma consequent to allergic broncho- References pulmonary aspergillosis. Am Rev Respir Dis 1973;108:940-3.

6 Safirstein BH, D'Souza MF, Simon G, Tai EH-C, Pepys J. Five copyright. I Ward MJ, Davies D. Pulmonary aspergilloma after radiation year follow-up of allergic bronchopulmonary aspergillosis. Am therapy. Br J Dis Chest 1982;76:361-4. Rev Respir Dis 1973;108:450-9. 2 Long JP, McErlean DP, FitzGerald MX. Changing patterns of 7 Davies D. Lung fibrosis and cavitation mimicking tuberculosis. pulmonary aspergilloma [abstract]. Thorax 1981;36:224. Tubercle 1970;51:246-54. 3 Bosken CH, Myers JL, Greenberger PA, Katzenstein AA. Patho- 8 Ein ME, Wallace RJ Jr, Williams TW Jr. Allergic broncho- logical features of allergic bronchopulmonary aspergillosis. Am pulmonary aspergillosis-like syndrome consequent to asper- J Surg Pathol 1988;12:216-22. gilloma. Am Rev Respir Dis 1979;119:811-20. http://thorax.bmj.com/ on September 27, 2021 by guest. Protected