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This patient with longstanding pulmonary disease developed Mycobacterium avium pulmonary infection, which was treated. There was evolution in his bilateral upper lobe cavities and he presented with haemoptysis in 2003, positive aspergillus precipitins were found at that time. Chronic cavitary pulmonary aspergillosis was diagnosed. One year later chest X rays revealed a likely aspergilloma in the large right upper lobe cavity surrounded by some pleural thickening. Sputum cultures were still negative for aspergillus. Two years later the fungal ball in his right upper lobe cavity had substantially enlarged together with enlargement of the cavity itself. Nine months later after a severe bout of coughing large pieces of black material were coughed up. Following a chest X ray it was observed that the aspergilloma had disappeared.
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| Diagnosis: Aspergilloma (fungal ball) in context of CCPA which resolved following several severe coughing bouts.
Response to antifungal
therapy: The patient was treated with itraconazole and rifabutin, with sub-therapeutic serum concentrations. He developed azole resistance, but improved spontaneously following coughing up his whole aspergilloma.
Outcome: The patient continues to improve.
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