Endobronchial aspergilloma associated with idiopathic pulmonary fibrosis: a case report and review of the literature

To the editors,

Endobronchial aspergilloma (EBA) is considered to be a rare presentation of pulmonary aspergillosis. The rarity of EBA associated with idiopathic pulmonary fibrosis (IPF) prompted us to report the case to make a correct diagnosis.

A 69-year old non-smoking man presented to the hospital due to intermittent cough for 4 years and progressive dyspnea for 1 year. High Resolution Computed Tomography performed usual interstitial pneumonia pattern and a mass lesion in the left lower lung field. The patient was initially diagnosed as IPF associated with tumor or tuberculosis with the nonspecific clincal and radiological features. Fiberoptic bronchoscopy revealed an irregular whitish necrotic mass lesion which totally obstruct lateral branch on posterior basal segmental bronchus of the left lower lobe. EBA was diagnosed by histopathologic features of the slender septate hyphae with acute angle branching of the Aspergillus spp. in the necrotic lesion biopsied from the fiberoptic bronchoscopy (Figure 1). The EBA was disappeared after treated with oral voriconazole and with gradual partial removal of the lesion by bronchoscopy forceps. Finally, there was a bronchiectasis on posterior basal segmental bronchus of the left lower lobe after the therapy. So, EBA can be associated with IPF, because there is a tractional bronchiectasis. The pathological proofs are essential to diagnosis. And the endoscopic treatment combined with systemic antifungal medicine has been proved to have a good prognosis.

Fig. 1.

The histologic features of the necrotic lesion biopsied. Peryodik Asit Shift (10×100)

EBA is considered to be an unusually positioned aspergilloma (1) and a rare presentation of pulmonary aspergillosis. It can present as a noninvasive form of aspergillosis characterized by growth of Aspergillus spp. within the bronchi, with or without parenchymal lesions or cavities(2). In our case there was a tractional bronchiectasis on posterior basal segmental bronchus of the left lower lobe, so that may be the cause of endobronchial aspergilloma.

To our knowledge, our report is the first to describe IPF complicated by EBA. EBA dose not like the pulmonary aspergilloma which having an air crescent sign. Sometimes, it can mimic lung tumor(3). This case had no specific symptoms, laboratory examinitions and HRCT features. The TB could also not be excluded with the bronchoscopy performances. The case could be diagnosed as having lung cancer or TB without pathology. However, the (1, 3)-β-D-glucan was higher, which maybe help to diagnose. And the histological features with slender, septated hyphae that exhibit angular dichotomous branching in the same direction demonstrated the typical features of Aspergillus species in the necrotic lesion biopsied. Therefore, the case was diagnosed with EBA by the pathological proof.

Treatment of EBA has not yet been established, because it may be non invasive in immunocompetent host (4). Our paitent was treated with oral voriconazole 200 mg twice daily for 3 months and with gradual partial removal of the lesion in the bronchus by bronchoscopy forceps for 2 times once a month until completely cleared. The EBAwas disappeared after three months therapy and there were no side effects. Follow-up of 8 months, there was no recurrence until present. So our patitent was benifit from the medical treatments.

We can get three important clinical issues form our case. First, the Aspergillus species can infect the bronchial lumen of immunocompetent IPF patient, because there was a tractional bronchiectasis in IPF. Second, the classical CT features and the pathological proofs are essential to diagnosis, the other measures like Aspergillus-precipitating antibody test, Aspergillus galactomannan antigen test, (1, 3)-β-D-glucan assay and cultures of specimens have important accessory diagnostic value. Third, endobronchial aspergilloma may not need to be treated, but in our case, the endoscopic treatment combined with systemic antifungal medicine has been proved to be a good therapeutic method for endobronchial aspergilloma without any side effects. Therefore, the clinicians can give an accurate diagnose and provide a good treatment program with those above three points at the first time.