|Year : 2017 | Volume
| Issue : 1 | Page : 42-45
Aspergilloma in a hydatid cyst masquerading as pulmonary tuberculosis
Manu Chopra, C. D. S. Katoch
Department of Pulmonary Medicine, Military Hospital, Namkum, Ranchi, Jharkhand, India
|Date of Web Publication||29-Dec-2016|
LT Col. Dr. Manu Chopra
Department of Pulmonary Medicine, Military Hospital, Namkum, Ranchi, Jharkhand
Source of Support: None, Conflict of Interest: None
Aspergilloma is a saprophytic infection that colonizes preexisting lung cavities that presents as a fungal ball. Typically, an aspergilloma develops in cavities formed as a result of diseases such as tuberculosis, sarcoidosis, bronchiectasis, lung abscess, and cavitary neoplasia, but it has also been reported, though rarely, in pulmonary cavities as a consequence of the removal of a hydatid cyst. The clinical features of pulmonary aspergilloma, ruptured hydatid cyst, and tuberculosis are similar in the form of cough, hemoptysis, and low-grade fever. In a developing country like India, wherein pulmonary tuberculosis is the most common cause of a chronic cough with hemoptysis; we present an unusual case of aspergilloma in a ruptured hydatid cyst masquerading as pulmonary tuberculosis.
Keywords: Aspergilloma, bronchial artery embolization, echinococcosis, hemoptysis, hydatid cyst
|How to cite this article:|
Chopra M, Katoch C. Aspergilloma in a hydatid cyst masquerading as pulmonary tuberculosis. J Assoc Chest Physicians 2017;5:42-5
| Introduction|| |
Aspergillomas usually are seen in residual lung cavities. Pulmonary hydatid cysts are common in developing countries like India, but aspergilloma colonising a ruptured hydatid cyst and masquerading clinically and radiologically as Pulmonary tuberculosis is rare. We herein present a peculiar case of the same.
| Case Report|| |
A 43-year-old Army Jawan presented with productive cough, low-grade intermittent fever, and right-sided nonpleuritic, nonanginal chest pain of 4 months duration. He also gave a history of streaky hemoptysis and 3 kg weight loss in the past 3 months. There was no history of tuberculosis. He was a nonsmoker and denied any high-risk sexual behavior.
Clinically, his vitals were within normal limits. Systemic examination did not reveal any abnormality. His hematological and biochemical profile were within normal limits. ELISA for HIV was negative; Mantoux was 20 mm, sputum for acid fast Bacilli (AFB) (two samples) was negative, and sputum Mycobacterium tuberculosis (MTB) culture showed no growth. Chest X-ray at the time of admission on February 23, 2010 [Figure 1], showed patchy alveolar opacities in the right lower zone and right perihilar region with the areas of cavitation. Contrast-enhanced computed tomography (CECT) chest [Figure 2] showed a thick-walled cavity in the superior segment of the right lower lobe with an intracavitary mass; the surrounding lung parenchyma showed acinar opacities involving the right middle lobe and basal segments of right lower lobe. As the patient had been having ongoing hemoptysis, the CECT chest findings were attributed to pulmonary tuberculosis with most probably, a blood clot in the pulmonary cavity. His fiberoptic bronchoscopy (FOB) did not reveal any abnormality. Brocho-alveolar lavage (BAL) was negative for Gram-stain/AFB stain/fungal stain/pyogenic cultures/MTB cultures.
|Figure 2: Contrast-enhanced computed tomography chest, Feb 2010 (prior to starting ATT)|
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Based on his clinical and radiological profile, he was diagnosed to be a case of smear-negative pulmonary tuberculosis and was started on antitubercular therapy (ATT) (EHRZ). He showed a satisfactory response to ATT with a resolution of fever, cough, hemoptysis, chest pain, and gained weight. He gained 7 kg weight on ATT. His repeat chest X-ray [Figure 3], 4 months after starting ATT, showed a significant clearing of parenchymal lesions. He had persistence of a thin-walled cavity in the right perihilar regions with intracavitary mass. He was given 6 months of ATT and was kept under follow-up.
He became symptomatic again after 6 months of stopping ATT with recurrent episodes of hemoptysis. He had no constitutional symptoms. Clinically his vitals were within normal limits. The systematic examination was also normal. Chest X-ray [Figure 4] showed a nonhomogeneous opacity in the right parahilar region. CECT chest [Figure 5] showed a thick-walled cavity in the superior segment of the right lower lobe with surrounding consolidation and freely mobile intracavitary mass lesions suggestive of aspergilloma. FOB did not reveal any abnormality. Sputum and BAL were negative for Gram-stain, fungal stains, AFB stains or pyogenic, and fungal or MTB cultures. He was suspected to be suffering from aspergilloma in an old, healed tubercular cavity. He was subjected to bronchial artery embolization using 300–500-micron poly vinyl alcohol particles; during the procedure, imaging revealed hypervascularity, neovascularization, and arteriovenous shunting of the right bronchial artery. He continued to have hemoptysis and was taken up for the right lower lobectomy. Peroperatively, the middle lobe was found collapsed, thus lobectomy of both right middle and lower lobes was carried out.
|Figure 5: Contrast-enhanced computed tomography chest, Feb 2011, (After 6 months of stopping ATT)|
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On gross examination, the superior segment of the right lower lobe had a thick-walled cavity with intracavitary collapsed pearly white membrane [Figure 6]a and [Figure 6]b. Microscopic examination of the same revealed chitinous membrane of dead hydatid cyst with acute angle branching fungal hyphae and spores suggestive of aspergilloma growing in a hydatid cyst. The rest of the lung parenchyma showed signs of chronic inflammation but had no invasion of fungal hydatid cysts [Figure 7]a-[Figure 7]d.
|Figure 6: (a and b) Gross specimen thick-walled cavity with intracavitary collapsed pearly white membrane|
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|Figure 7: (a) Microscopic examination chitinous membrane of dead hydatid cyst, (b) Chronic inflammation, (c) acute angle branching fungal hyphae and spores, and (d) fungal stain|
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The individual had aspergilloma in an old ruptured hydatid cyst. The initial clinical and radiological response to ATT could not be explained. This case represents a rare case wherein aspergilloma had been growing on an old ruptured hydatid cyst, masquerading as pulmonary tuberculosis, and showing not only clinical but also significant radiological response to ATT. The patient is presently asymptomatic and is under follow-up.
| Discussion|| |
Aspergilloma, the most common form of pulmonary aspergillosis, commonly develops in preexisting lung cavities due to tuberculosis, bronchiectasis, ankylosing spondylitis, sarcoidosis, or pulmonary infraction.
Though aspergilloma can occur in hydatid cyst cavities, it is usually found in postoperative cavities of hydatid cyst., Hydatid cyst most commonly develops in liver (60%) and lungs are affected in 20–30% of cases. In pulmonary hydatid disease, the cysts are most commonly seen in the right lower lobe (53%). Single cysts are most common (72–83%) with an intact cyst. Most of the pathology results from space occupying lesion affecting nearby structures. The one-third of diagnosed cases of pulmonary hydatid cyst present following cyst rupture or the development of secondary cyst infection. Pulmonary symptoms occur in 67–89% of patients with pulmonary cysts. The most commonly reported symptoms are cough, fever, and chest pain. Occasionally, hemoptysis can occur, and rarely, bilioptysis, pneumothorax, or pleuritis may also occur. With rupture of the cyst into a bronchus, hydatid vomica of cystic contents can occur: Clear, salty, or peppery fluid with or without hemoptysis.
Although our patient had constitutional and endobronchial symptoms which can be seen in a case of ruptured hydatid cyst, the possibility of tuberculosis was kept high on cards as the presentation matches active pulmonary tuberculosis. Moreover, the patient showed significant clinical and radiological improvement with ATT as shown in chest X-rays.
The coexistence of aspergilloma in a hydatid cyst in an immune competent case has been found very rarely. There are few case reports wherein postoperative histology or fine-needle aspiration cytology samples of pulmonary echinococcal hydatid cyst showed concurrent infection of aspergillus in a previously unoperated pulmonary hydatid cyst.
A retrospective study to reevaluate the coexistence of aspergillosis and echinococcosis in archival materials revealed two cases of aspergillosis and hydatid cyst coexistence out of 100 reevaluated archival cases with a diagnosis of hydatid cyst.
To conclude, in a country like India, where tuberculosis and echinococcosis are both endemic, a possibility of ruptured hydatid cyst should be kept in mind, in cases with endobronchial and constitutional symptoms suggestive of pulmonary tuberculosis, especially when the lesions are in the middle or lower lobes. Although aspergillosis is a rare disease, this case shows aspergilloma in a ruptured hydatid cyst confusing as pulmonary tuberculosis.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]