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CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 99-101

Aspergillus nodule, a rare variant of chronic pulmonary aspergillosis mimicking as lung cancer


1 Department of Respiratory Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Pathology, T. S. Misra Medical College and Hospital, Lucknow, Uttar Pradesh, India
3 Department of Ophthalmology, Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh, India

Date of Submission13-Jul-2020
Date of Acceptance15-Dec-2020
Date of Web Publication25-May-2021

Correspondence Address:
Dr. Hemant Kumar
Department of Respiratory Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjmsr.mjmsr_29_20

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  Abstract 


Chronic pulmonary aspergillosis includes several disease manifestations, including aspergilloma, Aspergillus nodules, chronic cavitary pulmonary aspergillosis, and chronic fibrosing pulmonary aspergillosis. Although rarely reported in the literature, Aspergillus nodules can occur in immunocompetent hosts, may be single or multiple, and may or may not have cavitation within them. Because of similar clinical presentation of Aspergillus nodule and lung cancer, the diagnosis of Aspergillus nodule becomes delayed leading to increased mortality and morbidity. Here, we are reporting a case of lung nodule initially suspected for lung carcinoma but turn out to be an Aspergillus nodule after histopathological examination.

Keywords: Aspergillosis, histopathological examination, immunocompetent


How to cite this article:
Pandey MK, Kumar H, Mishra P, Kalra SM, Gupta P. Aspergillus nodule, a rare variant of chronic pulmonary aspergillosis mimicking as lung cancer. Muller J Med Sci Res 2020;11:99-101

How to cite this URL:
Pandey MK, Kumar H, Mishra P, Kalra SM, Gupta P. Aspergillus nodule, a rare variant of chronic pulmonary aspergillosis mimicking as lung cancer. Muller J Med Sci Res [serial online] 2020 [cited 2021 Jun 23];11:99-101. Available from: https://www.mjmsr.net/text.asp?2020/11/2/99/316692




  Introduction Top


Aspergillus is a ubiquitous saprophytic fungi found in the environment. It is responsible for several disease manifestations in human being. The clinical presentation, course, and prognosis of Aspergillus infection mainly depend on the immune status of the host, genetic predisposition, underlying lung pathology and prior infection. Invasive aspergillosis is a severe form of Aspergillus manifestation occurs in patients with profound immunosuppression such as organ transplant recipients, the patient undergoing chemotherapy, or on prolonged steroid therapy. Chronic pulmonary aspergillosis (CPA) presents in a more indolent fashion, usually affecting patients with underlying lung pathology, but with no or only subtle immune suppression. The most common form of CPA is chronic cavitary pulmonary aspergillosis, which may progress into chronic fibrosing pulmonary aspergillosis if untreated. Less common manifestations of CPA include Aspergillus nodule and aspergilloma.[1] Aspegillus nodue in the immunocompetent patient with healthy lung has been a rare finding, with few cases reported from the literature. Herewith, in this case report, we will discuss a case of a previously healthy middle-age female presenting with streaky hemoptysis and imaging shows solitary pulmonary nodule on radiograph and was found to be an Aspergillus nodule after histopathological examination.


  Case Report Top


A 53-year-old female patient presented to our hospital with complaints of streaky hemoptysis for the last 1 month. There was no history of fever, loss of weight, similar complaints, and treatment history, including antitubercular therapy in the past. General physical examination is within the normal limits. Complete blood cell count revealed hemoglobin 9.0 g%, total leukocyte count 9000 cell/mm3 (polymorphs 62%, lymphocytes 30% eosinophils 3%, monocytes 5%), and random blood sugar were 86 mg/dl. ELISA test for HIV was negative. Sputum examination for acid-fast bacilli, gene-Xpert, and gram stain was negative. Chest X-ray posteroanterior view shows heterogeneous opacity with irregular margins involving left middle and lower zone suspicious for pulmonary nodule [Figure 1]. After 2 weeks of antibiotic therapy, patients were not improved clinically as well as radiologically. Contrast-enhanced computed tomography (CT) scan thorax was advised, which revealed irregular mildly enhancing mass lesions of the size of 2.8 cm × 1.9 cm with spiculated margins in the superior basal segment of left lower lobe suspicious for malignant nodule [Figure 2]. Patient undergone CT-guided biopsy from mass lesion which revealed long slender fungal hyphae with septation and branching in the background of necrosis, consistent with the morphology of Aspergillus species after confirming with periodic acid-Schiff stain [Figure 3]. The patient was diagnosed with pulmonary Aspergillus nodule and started itraconazole therapy.
Figure 1: Chest X-ray posteroanterior view showing heterogeneous opacity with irregular margins involving left middle and lower zone

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Figure 2: Contrast-enhanced computed tomography scan thorax showing irregular mildly enhancing mass lesions of the size of 2.8 cm × 1.9 cm with spiculated margins in the superior basal segment of the left lower lobe

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Figure 3: Histopathological examination with periodic acid-Schiff stain from mass lesion showing long slender fungal hyphae with septation and branching in the background of necrosis, consistent with the morphology of aspergillus

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  Discussion Top


Aspergillus is a ubiquitous fungus that causes a variety of clinical syndrome in human being. Although the method of transmission from one person to another is invariably by inhalation of the ubiquitous spores, only a few cases develop lung disease. The severity of illness in affected individuals depends on immune status or defective pulmonary defense such as mannose-binding lectin deficiency or immune dysregulation such as T helper 2 cell axis predominance.[1] CPA is a progressive and less invasive pulmonary infection. It is commonly associated with underlying pulmonary conditions such as tuberculosis, emphysema, and diffuse parenchymal lung disease that lead to the formation of cavities, bullae, scaring, or nodules in the lungs.[2] Few cases have been reported on CPA, which presents as single or multiple nodule(s) without underlying lung pathology in immunocompetent hosts. Aspergillus nodule frequently colonize in the upper lobe and have well-defined margins on CT scan.[3] In our case, it involves the lower lobe and have spiculated margins, which is an uncommon finding. The diagnosis of an Aspergillus nodule may be challenging because of nonspecific clinical presentation radiological findings. In this study, hemoptysis alone was the most common clinical feature. The diagnosis of an Aspergillus nodule can be made in an immunocompetent patient in whom lung malignancy has been excluded by the combination of the nodular lesion on lung imaging and either a percutaneous (CT or ultrasound guided) or surgical lung biopsy showing Aspergillus in tissue or a positive Aspergillus IgG titer in blood.[4] In our case, the diagnosis of Aspergillus nodule was made on the basis of demonstration of fungal hyphae in the biopsy tissue.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Denning DW, Riniotis K, Dobrashian R, Sambatakou H. Chronic cavitary and fibrosing pulmonary and pleural aspergillosis: Case series, proposed nomenclature change, and review. Clin Infect Dis 2003;37 Suppl 3:S265-280.  Back to cited text no. 1
    
2.
Smith NL, Denning DW. Underlying conditions in chronic pulmonary aspergillosis, including simple aspergilloma. Eur Respir J 2011;37:865-72.  Back to cited text no. 2
    
3.
Yoon SH, Park CM, Goo JM, Lee HJ. Pulmonary aspergillosis in immunocompetent patients without air-meniscus sign and underlying lung disease: CT findings and histopathologic features. Acta Radiologica 2011;52:756-61.  Back to cited text no. 3
    
4.
Denning DW, Cadranel J, Beigelman-Aubry C, Ader F, Chakrabarti A, Blot S, Ullmann AJ, Dimopoulos G et al. Chronic pulmonary aspergillosis: Rationale and clinical guidelines for diagnosis and management. Eur Respir J 2016;47:45-68.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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