TB or Not TB? Pulmonary Aspergillosis in the Setting of Suspected Tuberculosis

INTRODUCTION: Pulmonary aspergillosis can present in a multitude of ways, whether it be invasive, allergic, cavitating, or chronic necrotizing disease.The pattern and severity of presentation is determined largely by a patient's underlying lung integrity.Aspergillosis colonization is a known sequela of and presents similarly to pulmonary tuberculosis (TB).Treatment therefore requires addressing both the active infection and the underlying cause and comorbidities.Here we present a case demonstrating a therapeutic challenge in a patient with multiple diagnostic considerations.CASE SUMMARY: A 60-year-old gentleman with a past medical history of COPD presented with fatigue, decreased appetite, and worsening dyspnea for two months.Decades prior, the patient had been lost to follow up during treatment for TB.On examination, the patient was in mild distress, severely cachectic with a BMI of 12, and had swollen extremities.Scattered rhonchi were heard on lung auscultation.The oxygen saturation was 92% while receiving supplemental oxygen via nasal cannula at four liters per minute.CT of the chest revealed cavitary lesions in the apices of both lungs, with centrilobular emphysema and left lower lobe consolidation.Testing was negative for common pathogens, including tuberculosis.Bronchoalveolar lavage cultures were positive for Aspergillus fumigatus.Treatment with broad spectrum antibiotics, voriconazole, and enteral nutrition was initiated, however the patient continued to decline and subsequently died.DISCUSSION: This case overall highlights the emphasis needed to be placed on coexisting diagnoses of Aspergillosis and untreated TB.One condition may supersede the other and fail to manifest as in this case.This patient was treated aggressively for Aspergillus; and in this instance, the risk-benefit analysis warranted crossing one bridge at a time, with antifungal treatment alone taking precedence over adjunct TB therapy.In managing patients with aspergillosis and tuberculosis it is critical to be mindful of the consequences of untreated conditions and to timely discern when and whether or not to treat.