A 60 year-old male presented with one month history of fever, which was associated with cough and expectoration, shortness of breath for the previous 5 days. He was a known asthmatic for past 9 years for which he was receiving combination of inhaled salmeterol, fluticasone and oral salbutamol. He also took Ayurvedic medication. Subsequently, he was diagnosed to have developed allergic bronchopulmonary aspergillosis (ABPA) on the basis of a positive skin test, presence of central bronchiectasis and elevated levels of specific serum IgE. He was treated with oral steroids for 6 months, which were tapered off in view of symptomatic improvement. The fever recurred after one year but subsequently he deteriorated. A culture of bronchoalveolar lavage fluid revealed growth of Aspergillus fumigatus.
Chest X-rays, CECT and HRCT showed bilateral upper zone and midzone consolidation and bilateral pleural effusion, both lower lobes showed bronchiectasis, progression of the lesions was seen. The patient's condition progressively deteriorated during his hospital stay and he succumbed to his illness following a cardiorespiratory arrest.
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Diagnosis:
ABPA with widely disseminated invasive aspergillosis detected at postmortem. Invasive aspergillosis complicating ABPA is rare. Clearly a positive culture of Aspergillus in his respiratory fluids is unhelpful in this seting. Aspergillus antigen might also be positive on BAL fluid, but if positive in blood, would be suggestive (probable diagnosis) of IA.
Response to antifungal therapy:
He received no treatment.
Outcome:
The patient died but widespread aspergillosis was not suspected.
Case details kindly provided by Professor Arunaloke Chakrabarti Division of Mycology, Postgraduate Institute of Medical Education, Chandigarh, India
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