Case 078: Mucoid impaction, localised bronchiectasis and surgery (upper lobectomy) in a patient with ABPA
Summary:

This 35 yr old female patient  was an asthmatic who presented with a cough. A chest X ray showed a left upper lobe mass, further tests showed an allergy to “fungal spores”. She was diagnosed with ABPA, improved with itraconazole treatment but was left with a localised area of bronchiectasis. Given her young age and good lung condition she underwent an upper lobectomy. IMAGES

Comments:

Diagnosis:
The diagnosis of ABPA was made on the basis of chest infiltrates, that cleared, a raised total IgE, raised specific IgE and skin test to Aspergillus, bronchiectasis, in the context of asthma. Sputum was also positive for A fumigatus. The very high Aspergillus IgG is consistent with chronic pulmonary aspergillosis or Aspergillus bronchitis, probably in the area of bronchiectasis. Her mannose binding lectin deficiency may have contributed to bronchiectasis (conjecture).

Management:
She clearly improved symptomatically with itraconazole, but was left with a localised area of bronchiectasis. Given her young age, and relatively well preserved lungs in other areas, surgical removal was helpful in removing a focus for continuing infection. The surgical risk of the procedure includes an overall 3% mortality (less in younger people), and post-operative complications such as a persistent air leak, pain in  the chest and other rare complications. Fortunately she appeared to have none of these.
Outcome:
This patient at follow up  8 weeks post surgery had no symptoms and a good exercise tolerance. Sputum samples were negative for Aspergillus by PCR and by culture. Chest  X ray showed the remaining lungs remain clear, with no focal  lung lesion and no pneumothorax.

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