Allergic Bronchopulmonary Aspergillosis Presenting as Pyopneumothorax: Expanding the Clinical Spectrum

ABSTRACT: Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus fumigatus usually seen in asthmatic individuals, with pleural involvement being exceedingly uncommon. We describe a 23-year-old female with poorly controlled asthma who presented with progressive dyspnoea, chest pain, and left pyo-pneumothorax. Imaging demonstrated complete obstruction of the left main bronchus by a mucus plug with evidence of contralateral bronchiectasis. Laboratory evaluation revealed markedly elevated total IgE levels (6351.8 IU/mL) and raised specific IgE and IgG antibodies to A. fumigatus , fulfilling the modified ISHAM diagnostic criteria for ABPA. The patient was managed with systemic corticosteroids and itraconazole, leading to significant symptomatic and radiological improvement, with resolution of the air leak although minimal pleural thickening persisted as sequela. Pleural disease in ABPA is rarely reported, with published cases including effusion, hydropneumothorax, empyema, and pyo-pneumothorax, attributed to immune-mediated pleural inflammation, secondary infections related to therapy, or advanced fibrotic disease. Misdiagnosis as tuberculosis is frequent in endemic regions due to overlapping radiological features, often delaying appropriate therapy. Our case adds to the limited literature by highlighting pyo-pneumothorax as a potential presentation of ABPA, expanding its clinical spectrum beyond the conventional manifestations. The favorable outcome following combined corticosteroid-antifungal therapy reinforces the importance of early recognition and multidisciplinary management to prevent morbidity associated with such complications. Clinicians should remain vigilant when evaluating pleural involvement in asthmatics with elevated IgE and bronchiectasis, as timely diagnosis and targeted treatment can significantly improve outcomes.