Chronic Necrotising Pulmonary Aspergillosis and pleural thickening worsened by steroids and then surgery

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This 66 year old life long non-smoker attended clinic with a 3 month history of increasing shortness of breath, cough, lethargy and a 10kg weight loss. In 1988 he underwent a routine chest radiograph prior to a hernia repair which had demonstrated pleural thickening on the left. A chest radiograph showed extensive left pleural thickening the lung. A CT scan of the thorax showed a large cavitating mass in the left apex. This was biopsied and showed necrotic debris containing hyphae consistent with Aspergillus. Initially he was treated with corticosteroids but the cavity expanded rapidly with steroids;as he failed to improve, he was referred for surgery and steroids stopped. He underwent a left pneumonectomy - the parietal pleura was extremely thick. At the apex of the upper lobe an open cavity was present. The cavity material contained a ball of fungal hyphae, "consistent with a fungal empyema." The patient did well until he developed further weight loss and other general symptoms. A left lateral chest wall fenestration was done in mid January 2000 involving the removal of four ribs. Histological examination did not reveal evidence of aspergillosis. Multiple organisms were grown subsequently from the huge chest defect, including Aspergillus fumigatus (itraconazole MIC 0.25µg/ml). A debridement of the fenestation was done in mid February; a mass of tissue at the apex, presumed to be Aspergillus, which was also removed. Oral itraconazole was started, the patient's condition worsened and he expired


  • Aspergillus fumigatus