Images in Interventional Pulmonology
An aspergilloma is a mixture of fungal hyphae, inflammatory cells, fibrin, and mucus that usually colonizes a cavity.1,2 The common presentation is usually an intrapulmonary aspergilloma occupying the preexisting lung cavity from tuberculosis or lung cancer. In rare cases aspergilloma can form in the pleural space, usually following a surgical procedure and/or bronchopleural fistula (BPF).3,4 We present a case of postlobectomy pleural aspergilloma that was confirmed by bronchoscopic visualization of the fungus ball in the pleural space through the BPF, which resolved completely with medical management.
We present a case of a 67-year-old white male with COPD and stage IIA squamous cell lung cancer, status post a right upper lobectomy and adjuvant chemotherapy in January 2013. His postoperative course was complicated by development of a BPF, which was managed conservatively. In March 2014, he presented with worsening dyspnea, right-sided pleuritic chest pain, and productive cough. Chest CT revealed a persistent BPF leading to a 5×6 cm cavitary lesion in the right upper pleural space (Fig. 1A). The patient underwent bronchoscopy which confirmed the presence of a BPF leading to the pleural space which was filled with a yellow cheesy mass consistent with a fungus ball. This was confirmed with forceps biopsy that revealed Aspergillus fungal hyphae with inflammatory cells (Fig. 1B). Surprisingly the fungal culture was positive for A. niger and not A. fumigatus, which is a more frequent cause of aspergillomas.5–7
Because of the patient’s poor lung function and personal preference, we opted for monotherapy with oral voriconazole. After 5 months of treatment, the patient reported significant improvement in his symptoms. A follow-up CT scan revealed persistence of the BPF with complete resolution of the previously seen pleural aspergilloma (Fig. 1D). Unfortunately, in 2015 the patient was found to have another left upper lobe nodule for which he needed a repeat bronchoscopy, during which we were able to inspect the right-sided BPF with no evidence of previously visualized pleural aspergilloma (Fig. 1C).
Unlike pulmonary aspergilloma, intrapleural aspergilloma, defined by the presence of aggregate of hyphal macrocolonies forming mass in the pleural cavity, is a very rare entity. More commonly it is associated with lung resection with postoperative BPF and thoracostomy for tuberculous empyema.5,8 Data regarding the treatment of pleural aspergilloma are limited to case series and case reports. Different treatment approaches with variable success rates have been described including open thoracotomy, chest tube thoracostomy with local instillation of antifungal agents, or nebulized liposomal amphotericin. The treatment approach should be tailored to the patient’s preference, underlying etiology, and cardiopulmonary status.9 In 1 case series reported by Guazzelli et al, although their most common approach was open thoracotomy followed by antifungal instillation, 1 out of their 6 patients was treated with itraconazole and discharged home.9
Systemic antifungal therapy has always been considered to have a limited efficacy in treating aspergilloma.10 In our case, we elected to use medical management because of patient’s preference and limited cardiopulmonary reserve. Even though most of the previously reported cases used itraconazole for medical management of aspergilloma, we elected to use voriconazole based on the current guidelines from the Infectious Diseases Society of America, which describe emerging resistance to itraconazole.7 We were able to achieve a complete resolution of the fungus ball with medical therapy alone, underscoring the importance of attempting medical management before considering aggressive surgical interventions, especially as most affected patients are at high risk on account of multiple pulmonary comorbidities.
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