B72-36 Old Cavities, New Culprit: Aspergillus Fumigatus Infection Presenting as Hemoptysis

Abstract Introduction Aspergillus is a filamentous fungus that flourish in moist conditions such as soil and plants, and is airborne through dispersion of its spores. The common human pathogen is Aspergillus fumigatus (AF), which enters through the respiratory tract and rapidly multiplies. Patients with pre-existing lung disease can have clinically significant effects. We present a case in which a patient with a history of lung cavitations presents with hemoptysis, with the source being aspergilloma complicated by a possible bronchopleural fistula (BPF). Case Presentation A 65-year-old male with a history of prior lung cavitations deemed to be due to mycobacterium avium-intracellulare complex (MAI) and recurrent hemoptysis presented with a productive cough, fever, tachycardia, and tachypnea. Computed tomography (CT) of the chest was obtained revealing fibrotic changes and scarring as well as bronchiectasis in the left upper lobe. There was also apical pleural thickening and adjacent subpleural bullae, and multiple small pleural plaques with coarse calcifications. Additionally, an opacity is noted with surrounding air and pleural thickening, representing a possible mycetoma [Image 1]. He developed hemoptysis, for which the patient noted was recurrent in the past two years. Acid fast bacillus sputum cultures resulted positive for MAI. Due to poor response to antibiotic treatment through this course and possible concern for fungal infection, bronchoscopy was performed. Bronchoalveolar lavage was performed and cultures were positive for AF. Discussion Aspergillomas thrive in avascular cavitary spaces as it attaches to the walls and triggers inflammatory space without invading surrounding lung tissue. With disease progression, hemoptysis can occur as the aspergilloma directly invades the capillaries of wall linings or there is mechanical irritation of the vessels within the cavity. Our patient additionally may have had a BPF, likely formed from a history of recurrent lung cavitary pneumonia. This creates a direct pathway between airway and pleura space, allowing for inoculation of airborne pathogens such as AF. It also was a contraindication to performing a biopsy as it could worsen the patient’s BPF and potentially disseminate the possible fungal infection. Management requires medical and surgical strategies, as antifungal therapy alone may not be curative in the presence of an open tract. This abstract is funded by: None