Letters to the Editor
To the Editors:
We report a case of an aspergilloma caused by Aspergillus versicolor in a patient with previously undiagnosed congenital pulmonary airway malformation. We believe this is the first report to describe an aspergilloma caused by this rarely pathogenic species in an immunocompetent host.
A 15-year-old previously healthy female presented to the emergency department with 14 months of chronic cough. The patient had been evaluated 6 months earlier by an outside physician who diagnosed pneumonia and asthma and treated the patient with antibiotics and bronchodilators. Despite this, she continued to have symptoms of intermittent fevers and cough and subsequently developed occasional hemoptysis and difficulty breathing. Workup prior to admission included a chest radiograph and a computed tomography scan of her chest, which showed 2 cavitary lesions in the left lower lobe with air fluid levels for which she was admitted to the hospital.
The patient was afebrile with stable vital signs. She was nontoxic appearing. She had markedly diminished breath sounds over the left lung base, with dullness to percussion over the left chest.
Therapy was empirically started with ceftazidime and clindamycin for bacterial lung abscess. The patient had a normal white blood cell count and the sputum culture was negative for bacteria. Quantiferon gold and purified protein derivative tests were negative. The patient did have positive serum markers for beta-D glucan and galactomannan. Sputum grew A. versicolor. Evaluation revealed no underlying immunodeficiency. Of note, we found on further history and subsequent testing that flooding in the patient’s basement had increased the fungal burden of air in the patient’s home. We suspect that this altered air quality was the origin of this infection.
The patient was treated with voriconazole. Although symptoms improved, her chest radiograph showed persistent cystic lesions, and beta-D glucan and galactomannan levels remained elevated. Magnetic resonance imaging revealed a congenital pulmonary airway malformation without sequestration. The patient subsequently underwent a lobectomy, after which her serum fungal markers trended down and eventually became negative. Following levels of these fungal markers was useful in monitoring disease activity in our immunocompetent patient.
Aspergillus usually causes aspergillomas in immunocompromised hosts.1 Aspergilloma has also been described to complicate preexisting lung cavities. Review of literature revealed these to occur mainly in patients with tuberculous disease,2 but there have been 2 previously documented cases of an aspergilloma appearing in a congenital pulmonary airway malformation.3,4
The most common species of Aspergillus to cause invasive disease is Aspergillus fumigatus, described in >90% of cases,1 but other pathogenic species have been described. Our case is unique in that A. versicolor is rarely pathogenic and, to our knowledge, has never been reported to cause aspergilloma in an immunocompetent host. Our review of the literature revealed only 1 prior report of invasive A. versicolor disease, a case of ventilator associated pneumonia in a critically ill patient.5
Sara Kane, DO
Jamie M. Pinto, MD
Department of Pediatrics
Charles K. Dadzie, MD
Department of Pediatric Pulmonology
Maria Agnes C. Dawis, MD
Department of Pediatric Infectious Disease
Jersey Shore University Medical Center
K. Hovnanian Children’s Hospital, NJ
1. Denning DW. Invasive aspergillosis Clin Infect Dis. 1998;26:781–803
2. Davies D, Heaf PJD. Aspergillus in persistent lung cavities after tuberculosis. A report from the Research Committee of the British Tuberculosis Association Tubercle. 1968;49:1–11
3. Yonker LM, Mark EJ, Canapari CA. Aspergilloma in a patient with an occult congenital pulmonary airway malformation. Pediatr Pulmonol. 2012;47:308–310
4. Feng A, Cai H, Sun Q, et al. Congenital cystic adenomatoid malformation of the lung in adults: 2 rare cases report and review of the literature Diagn Pathol. 2012:7–37
5. Charles MV,, Pravin J, Noyal M, et al. Invasive pulmonary aspergillosis caused by Aspergillus versicolor
in a patient on mechanical ventilation AMJ. 2011;4:632–634