A Ball of Fun: Allergic Bronchopulmonary Aspergillosis Presenting as a Pneumothorax

R. Powers1, D. Sese2, A. R. Cucci2;

Author address: 

1Internal Medicine, Akron, OH, United States, 2Cleveland Clinic Akron General Medical Center, Akron, OH, United States.

Abstract: 

Introduction
Allergic Bronchopulmonary Aspergillosis (ABPA) presenting as pneumothorax is rarely reported and its association with chronic obstructive pulmonary disease (COPD) even less so. In these patients, there is a theorized association with hypersensitivity in genetically predisposed individuals. 1 
A 74 year old female with chronic respiratory failure from COPD presented with acute shortness of breath secondary to a right sided pneumothorax. She required chest tube placement and was intubated. Her initial chest imaging showed a right perihilar mass versus lymphadenopathy . She had diffuse wheezing and decreased breath sounds bilaterally. Her complete blood count showed a white blood cell count of 20.4 thou/cmm with neutrophilic predominance. She was treated empirically for aspiration pneumonia with broad spectrum antibiotics, however, her respiratory status continued to worsen hence a chest computerized tomography (CT) scan was obtained showing dilated and mucoid impacted bronchi suggestive of allergic bronchopulmonary aspergillosis with a cavitary lesion and internal fluid suggesting an aspergilloma. There were areas of centrilobular emphysema and a left 7 x11 mm lung nodule. Her respiratory cultures grew Aspergillus fumigatus. She was discharged home on IV antifungals with a plan for follow up CT scan in 1-2 months. At the time of discharge, her pneumothorax had resolved. Other than osteoporosis and hypertension, her past history consisted of COPD that was treated with inhaled long acting bronchodilator with steroids as well as a long acting anti-muscarinic agent. She smoked 60 pack years and quit ten years prior.
Discussion
A pulmonary aspergilloma is a non-invasive, intracavitary pleural growth caused by the ubiquitous saprophytic Aspergillus species. The spectrum of pulmonary disease as influenced by host immune status include simple colonization, hypersensitivity lung diseases such as ABPA,, mycetoma growth, and more severe invasive infections.1,2 Predisposing factors include structural lung disease causing cavitary lesions and dilated bronchi; classic associations include tuberculosis 1,3,4,5 Patients can present with hemoptysis, dyspnea, chest pain and cough. 1,4,6 However, many patients can have an asymptomatic presentation. Radiographic findings include a rounded mass with air crescent sign.4 Pneumothorax is a rarely reported initial presentation for aspergilloma, although it has been described as a complication.
Conclusion
Usually associated with cystic fibrosis and asthma, there are now several case reports describing ABPA in patients with COPD. Our immunocompetent patient had no known cavitary lung lesions and is a rare presentation of primary aspergilloma secondary to ABPA presenting as pneumothorax with only one other case reported in literature.1,9,10,11

Tables: 

2018

abstract No: 

A6772 / P1326

Full conference title: 

The American Thoracic Society Conference 2018
    • ATS 2018