Introduction Pulmonary Sarcoidosis usually presents as a nodular or acinar disease. Cavitation in sarcoidosis is considered rare and can become superinfected by invasive pulmonary aspergillosis which makes the diagnosis challenging. We present a rare care of cavitary sarcoidosis complicated by invasive aspergillosis. Case Report 30 year old African American Male presented initially to an outside hospital with complains of 1-2 tablespoons hemoptysis, 20 lb. weight loss and low grade fevers for 1 month. Past medical history was unremarkable for childhood infections or other co morbidities. Patient was an Iraq War Veteran with exposure to burn pits. Smoked cigarettes for 14 years total, quit a month before presentation and otherwise denied drugs or ETOH abuse. His initial CT chest showed extensive cavitary nodular infiltrates as well as hilar and mediastinal Lymphadenopathy. ACE and lysozyme levels were elevated. HIV and Tspot was negative. Bronchoscopy with bronchoalveolar lavage (BAL), EBUS and Navigational biopsy of the left upper lobe nodular lesion was done. Biopsy showed non necrotizing granulomas from all specimens with negative AFB and fungal stains and cultures. Histoplasma complement fixation (Y titer 1:32) was positive however urine and serum Histoplasma Ag and BAL fungal culture was negative. Patient was started on Prednisone but presented 2 weeks later with worsening hemoptysis. He underwent another bronchoscopy. BAL this time grew Aspergillus Fumigatus in addition to positive Aspergillus Galactomannan. Patient was started on Itraconazole for possible cavitary histoplasmosis and steroids were stopped. He continued to have worsening hemoptysis and was referred to our facility. Fungal antigens and serologies were repeated which were all negative however fungitell was elevated at 247. After reviewing the data including radiographic findings it was decided that patient may have invasive aspergillosis complicating an underlying cavitary disease. He was started on voriconazole for total of 6 months. Neutrophil function tests and immunoglobulin assays were negative. Open lung biopsy was done which revealed non caseating granulomas consistent with sarcoidosis. Patient was started on prednisone. After 6 months his symptoms improved significantly with chest CT showing near resolution of cavitations. Discussion Pulmonary cavitary lesions in the absence of concomitant comorbidities are an uncommon and often confusing manifestation of sarcoidosis. Prevalence of cavitary sarcoidosis is reported to be 2.8- 3.9%. Most often seen in stage 4 sarcoidosis. Up to 18% of cavitary sarcoidosis presents with aspergilloma on initial CT. Most frequently encountered complications include severe hemoptysis, pneumothorax and invasive aspergillosis.
Full conference title:
- ATS 2018