A 59-year-old woman presented with hemoptysis 16 years after a right pneumonectomy performed elsewhere for sequelae of pulmonary tuberculosis. The hemoptysis amounted to approximately 2 tablespoons once a week for a period of 3 months. There were no associated fevers, chills, or night sweats.
The hemoptysis began after the patient had fallen without sustaining a dehiscence, fracture, or significant soft-tissue injury, as determined by computer tomography scan of the chest. A lesser amount of hemoptysis had occurred 9 months earlier, which she attributed to hard brushing of her teeth.
The patient received medications for back pain, hypertension, and arthritis. She had been followed up for several years for small nodules in the left lung that remained stable. She had smoked earlier but there was no history of carcinoma. There was no history of fungal infection or mycetoma.
Bronchoscopy showed a green gelatinous structure with a pale margin apparently attached to a suture in the stump of the right mainstem bronchus (Fig. 1, upper right panel). The structure was relatively flat and had faint oblique striations (left upper and right lower panels). The material was removed in a single step by grasping with forceps and withdrawing the bronchoscope. This exposed 2 coils of apparent suture material (Fig. 1, lower left panel). The stump was completely intact. The gelatinous material was friable and fragmented when introduced into solution.
The gross specimen consisted of multiple fragments of grey/tan gelatinous tissue. Anatomic pathology microscopy showed mucous, acute inflammatory cells, and necrotic tissue. Grocott methanamine silver stain was positive for a few septate, nonpigmented fungal organisms. Cytopathology of washings from the bronchial stump showed rare degenerated benign bronchial epithelial cells and fungal hyphae. Acid fast bacilli smears and cultures were negative. Bacterial cultures showed 3+ Pseudomonas aeruginosa.
The patient received no specific treatment and had no recurrence of hemoptysis.
The bronchoscopic images showed a distinctive appearance of material in the pneumonectomy stump. Although the material had an organized appearance (Fig. 1), we believe the fungal hyphae in this specimen represent colonization rather than infection or a mycetoma. On account of fragmentation, further details of the macroscopic structures were not available.
Aspergillus fumigatus has the ability to form a biofilm on bronchial epithelial cells in vitro1 and can often be cultured from the sputum of patients with a variety of pathologic conditions. Bacteria also form biofilms in various settings.
Frank mycetomas with abundant fungal organisms have been reported to involve bronchial stumps.2,3 Bronchial mycetomas have also been reported in the absence of anatomic lesions of the airways.4,5 This case seems to fit somewhere between a biofilm and a mycetoma. We prefer the term “colony” in lieu of mycetoma for this case.
The anchor for the colony seems to have been suture material from the pneumonectomy. A plausible hypothesis is that trauma may have exposed the sutures that were then colonized. Colonization may occasionally be seen by thoracic surgeons, but this finding is seldom observed by general pulmonologists, in our experience.
Although hemoptysis led to bronchoscopy in this case, we could not diagnose the cause of hemoptysis with certainty. Signs of inflammation were lacking in the stump, there was no active bleeding, and there were no other lesions in the airways. The favorable outcome in our patient suggests that further action was not warranted.
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