Date: 23 January 2014
A 43 year old with smoking related emphysema was admitted to hospital with two separate episodes of haemoptysis. He had been in good health up to 1989, when he was diagnosed as having bilateral pulmonary tuberculosis. At that time a CT scan revealed a cavity in the left upper lobe (20.8cm2) with adjacent confluent infiltrates and pleural thickening. On bronchoscopic examination no abnormalities were noted and endobronchial biopsies did not reveal hyphae.
Over the next 4 years his condition deteriorated and a CT scan showed the left upper lobe cavity had increased to 40cm2. Itraconazole 400mg daily was prescribed. There was some clinical improvement on itraconazole but patient eventually deteriorated with breathlessness and with significant weight loss.
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Notes:
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Embolisation 7 – patient WC. Angiogram of the lateral thoracic artery on subtraction film showing grossly abnormal vasculature inferiorly shunting along several anterior intercostal arteries to the internal mammary artery. In addition a pseudoaneurysm is shown.
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Embolisation 6 – patient WC. Catheter tip in the lateral thoracic artery on screening film.
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Grocott (silver) stain showing branching septate hyphae fairly typical of Aspergillus in mucus. The apparent right angle branching is unusual.
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Bronchial mucosa under H & E stain showing numerous eosinophils deep to the mucosa, and mucus in the lumen of the bronchiole.
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Grocott (silver) stain showing branching septate hyphae fairly typical of Aspergillus in mucus. The apparent right angle branching is unusual.
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Severe kyphoscoliosis caused by greater than 40 years of prednisolone for ABPA and asthma.
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These pictures show remarkable curvature of the spine as a result of collapse of the vertebral bodies of the thoracic vertebrae. This is a gross example of steroid-induced osteoporosis. The dose was not large in the last 10 years, typically 5-10mg daily, but multiple high dose courses and slow tapering lead to this outcome.
Her corticosteroid warning card is also demonstrated, as additional steroids are required for any significant illness or surgery, as her adrenal glands had completely atrophied.
Kindly supplied by Prof David Denning, South Manchester University Hospitals NHS Trust, Manchester UK
(© Fungal Research Trust)
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