Allergic bronchopulmonary aspergillosis (ABPA) is an immunological pulmonary disorder caused by hypersensitivity to aspergillus fumigatus usually seen in patients with poorly controlled asthma, bronchiectasis and cystic fibrosis. The number of patients with ABPA worldwide is estimated to be about 5 million people, with ABPA in patients with asthma making up only 2% of this population. Computed tomography (CT) findings of ABPA are nonspecific but may include centrilobular nodules, scattered alveolar opacities and bronchiectasis. We present a case of ABPA presenting as a hyperdense lingular mass.
A 28-year-old male with medical history significant for mild intermittent asthma presented to the emergency department with new onset, sharp, left-sided chest pain. Chest x-ray showed a 6 cm left lung mass and CT of the chest showed a 6x4 cm lingular mass with postobstructive pneumonia concerning for malignancy (figure 1). The patient underwent endobronchial ultrasound with transbronchial biopsies that showed clusters of lymphoid cells. The procedure was repeated and the repeat biopsies showed markedly inflamed bronchial mucosa consisting of lymphocytes, plasma cells and eosinophils, consistent with ABPA. Pathology and flow cytometry were negative for malignancy. Serum immunoglobulin E showed a level greater than 2500 IU/ml (normal: less than 100 IU/ml) and serum eosinophilia.
The patient was ultimately treated with prednisone, itraconazole and prophylactic trimethoprim-sulfamethoxazole and was last followed-up in pulmonary clinic 8 months after initial presentation with almost complete resolution of symptoms and CT chest findings that were initially present.
ABPA is a rare and unrecognized and undiagnosed entity, with 30% of cases being misdiagnosed as tuberculosis. Treatment of ABPA is difficult and aims at reducing inflammation and generally includes a long course of corticosteroids. The role of antifungal medications is not clear in acute ABPA exacerbations. CT findings are usually nonspecific which makes the diagnosis more challenging to make and can result in delay to diagnosis. Common CT findings include bronchiectasis, centrilobular nodules, scattered alveolar opacities and mucus impaction, whereas perihilar infiltrates and pulmonary masses are uncommon, as seen in our patient.
figure 1 below
Full conference title:
- ATS 2018