Date: 26 November 2013
Born 75 years ago, Pt HK had 3 episodes of tuberculosis as a child and teenager, being treated with PAS and streptomycin. He suffered a ‘bad chest’ all his life and retired aged 54. Presenting with worsening and more frequent chest infections, he was referred with ‘bronchiectasis and Aspergillus sensitisation’. A diagnosis of chronic pulmonary aspergillosis was made in June 2009 on the basis of his chest radiograph and strongly positive Aspergillus precipitins (IgG antibodies) (titre 1/16). He also had Pseudomonas aeruginosa colonisation. His oxygen saturation was 87% and his pO2 6.8, pCO2 6.2 KPa.
His chest radiograph (see above, November 2009) was reported as showing; “ The lung fields are over-inflated. Bilateral apical fibrotic change secondary to old TB. No cavity seen.” At clinic, bilateral apical cavities were seen, with some associated pleural thickening at the left apex, without any evidence of a fungal ball.
He started posaconazole 400mg twice daily with therapeutic levels at subsequent visits. Sputum cultures never grew Aspergillus. Over the following 9 months he had no chest infections requiring antibiotics, his breathlessness worsened gradually and he remained easily fatigued. His Aspergillus antibody titres fell. Overall he felt better, but was concerned about declining respiratory status.
Copyright:
Fungal Research Trust
Notes: n/a
Images library
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Gross pathology demonstrating the great pleural thickness and two cavities (upper lobe and superior segment of lower lobe) with fragments of fungal mass.
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Histopathological appearance of a fungus ball. Note a conidial head resulting from fungal exposure to the air.
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Histopathological appearance of a fungus ball caused by Scedosporium apiospermum. The presence of anneloconidia differentiates it from Aspergillus.
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Chronic necrotising aspergillosis. Hyaline hyphal and calcium oxalate crystals obtained by needle aspirate biopsy from a diabetic patient with chronic necrotizing aspergillosis caused by Aspergillus niger (Papanicolaou, x 100).
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Aspergillus niger fungus ball and acute oxalosis. Higher magnification of adjacent replicate section.
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Oxalate crystals within renal tubuli (H&E, phase contrast, x 100). This patient developed acute oxalosis.
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Lung surface. Fungus ball, severe parenchymal fibrosis and pleural thickening.
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The periphery of the fungus ball is deeply eosinophilic because of the deposition of Splendore-Hoeppli material.
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