Craven County Schools Technology Center 2300 Old Cherry Pt Road New Bern, NC 28560 252.514.6393.
Case 1: Old PT with Aspergilloma
-
Upload
stanley-medical-college-department-of-medicine -
Category
Health & Medicine
-
view
1.982 -
download
2
description
Transcript of Case 1: Old PT with Aspergilloma
Prof.S.Sundar Unit
Present histroy
c/o hemoptysis-10epi 50-100ml/epi c/o cough and sputum-1month No h/o fever No h/o breathlessness No h/o chest pain No h/o LOW/LOA Noh/o hematuria No h/o hematemesis No h/o anticoagulation intake
Past histroy
No past h/o hemoptysis h/o treated PT one year before
Smoker Not a k/c of DM/SHT/CAD/ COPD
Non alcoholic
General examination
Conscious, oriented Afebrile Halitosis + No pallor No clubbing No cyanosis No pedal edema Not dyspneic No significant lymphadenopathy
Systemic examination
R.S-trachea midline flat chest cavernous BBS + left
infraclavicular
region B/L coarse crepts +Other system examination- normal
Investigations
CBC-WNL RFT -WNL Urine R/E- WNL ECG-WNL Sputum AFB-negative SputumC/S-Klebsiella sensitive
to amikacin,ciprofloxcine Serum IgE level- normal
Chest x-ray left UL cavity with
homogenous opacity within the cavity with semilunar air shadow CT Thorax conglumerate fibrotic mass Lesion doesnot enhance with
contrast-S/O Aspergilloma
Fungal c/s A.fumigatus grown in cultureKOH mount branching hyphal fragment
of aspergillus seenAspergillus precipitin test-positiveHIV/VDRL-nonreactive
DIAGNOSIS
Old treated pulmonary TB
Left upper lobe cavity Aspergilloma
CT-Surgery opinion left upper lobe aspergilloma Advised medical management
Chest medicine opinion Advised oral antifungal
TREATMENT
C.Itraconazole 100mg 2bd Packed RBC one unit Bronchodilator Inj.adrenochrome Inj.ciprofloxcin 200mg iv bd Bronchial arterial embolization
DISCUSSION ON ASPERGILLOSIS
CAUSED BY
A. fumigatus-most common A.flavus A.niger A.terreus A nidulans-immunocompromised
SPECTRUM OF PULMONARY ASPERGILLOSISHYPERSENSITIVITY REACTION Allergic bronchial asthma ABPA Extrinsic allergic alveolitis Bronchocentric granulomatosisINVASIVE INFECTION Invasive bronchial aspergillosis Chronic necrotizing pulmonary aspergillosis Invasive pulmonary aspergillosis Bronchial stump aspergillosisSAPROPHYTIC GROWTH IN PREEXISTING CAVITYSIMPLE COLONISATION
ASPERGILLOMA
Saprophytic colonization of Aspergillus in parenchymal lung cavity
Fungal ball lie free within the cavity or attached to cavitywall by granulation tissue
SECONDARY ASPERGILLOMA
Colonization and proliferation of fungus in a preexisting lung cavity
Tuberculosis cavity Sarcoidosis Histoplasmosis Blastomycosis AIDS pneumonia Lung abscess
Bronchiectasis Ankylosing spondylitis Rheumatoid nodules Pulmonary infarction Lung cancer
PRIMARY ASPERGILLOMA
Proliferation of aspergillus in bronchial tree leading to pulmonary cavity
CAUSESInvasive pulmonary aspergillosisChronic necrotizing pulmonary
aspergillosis Allergic bronchopulmonary
aspergillosis
CHEST X-RAY
Solid round mass within the cavity Partially surrounded by radiolucent
crescent-MONOD’S sign Movement of fungal ball in the
cavity Preexisting tuberculous cavities
the most common predisposing condition
CT- SCAN THORAX
Globules of gas are often seen within the interstices of the hyphal mass
CT ANGIOGRAPHYIdentifying hypertrophic
bronchial arteries that supply cystic wall of aspergilloma
SPUTUM CULTURES
Positive in 50% of the cases Not sensitivity and specific PRECIPITATING ANTIBODIES Positive in 95% of the cases
MANAGEMENT OPTIONS
Systemic or local antifungal Surgical resection Bronchial arterial embolization
Conservative management with carefull followup
INTRACAVITARY ANTIFUNGAL AGENTS CT guided percuteaneous
instillation of AMB Endobronchial instillation of
AMB via fiberoptic bronchoscopy
Indication-solitary aspergilloma with severe hemoptysis and contraindication for surgery
ORAL ANTIFUNGAL-ITRACONAZOLE Active against A.fumigatus High tissue penetration into the lung Dose 200-400mg/d for 6-18 months Symptomatic and radiographic
improvement in twothird of patients Major limitations- it works slowly recurrence after
discontinuation not usefull in severe
hemoptysis
SURGICAL RESECTION
Indications severe hemoptysis sarcoidosis chronic immunosuppression increasing titer of specific IgG single large cavity
BRONCHEAL ARTERIAL EMBOLIZATION Management of hemoptysis Only temporarily effective RADIATION THERAPY Indicated in recurrent lifethreatening hemoptysis after BAE
DIFFERENTIAL DIAGNOSIS
Lung cancer Pulmonary abscess wegener’s granulomatosis Bloodclot in a preexisting cavity
Disintegrating hydatid cyst
PREDICTORS OF POOR PROGNOSIS Progressive increase in size Multiple aspergillomas Severe underlying lung disease Immunosuppressive therapy AIDS Sarcoidosis Rising Aspergillus specific IgG Titer Repetitive episodes of severe
hemoptysis
Take home messsage
Aspergilloma-Rare disease BUT NOT VERY RARE
DISEASEImportant firstline D.D for evaluation of hemoptysis
THANK U