Pulmonary aspergillosis diagnosed during surgical treatment for spontaneous pneumothorax: a case report

Background Chronic pulmonary aspergillosis (CPA) is often asymptomatic; however, respiratory symptoms may trigger detection of the disease. Some asymptomatic patients are diagnosed as having CPA after closer examination of abnormalities on chest computed tomography (CT). We report a rare case in which CPA was diagnosed after surgery for spontaneous pneumothorax. Case description An 86-year-old man with old pulmonary tuberculosis and autoimmune hepatitis on oral prednisolone treatment developed a right-sided pneumothorax with persistent air leak and worsening subcutaneous emphysema. Despite thoracic drainage, his condition deteriorated. Chest CT showed numerous cysts and cavities with a small nodule in the right lung and interstitial changes bilaterally, although the precise site of the air leak was unclear. Thoracoscopy revealed adhesions, exudative pleural effusion, and a fibrinous exudate consistent with acute empyema. A 10-mm grayish necrotic mass was found to be adherent to the right upper lobe and to obstruct a 5-mm fistula. To avoid spillage, this material was removed en bloc, and thorough debridement and irrigation were performed. Suspecting fungal infection, we performed a wide wedge resection including the fistula site. Although intraoperative pleural fluid cultures were negative, Aspergillus fumigatus was grown from the resected necrotic material, based on which we initiated 3 months' treatment with oral voriconazole. The patient recovered uneventfully without recurrence noted until the 2-year follow-ups. Histopathology revealed atelectasis-related sclerosis with nodular scarring and dry necrosis, while fungal growth was confirmed in the lung cavity wall, indicating localized pulmonary aspergillosis complicating a pneumothorax. Conclusions In pneumothorax patients with cystic changes in the lungs arising from old healed pulmonary tuberculosis, the potential presence of CPA should also be considered. Even with exposure of fungal colonies in the thoracic cavity during pneumothorax surgery, appropriate intraoperative and postoperative measures could allow even elderly steroid-treated patients to recover completely without recurrence of CPA.