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Systemic dissemination of chronic necrotizing pulmonary aspergillosis in an elderly woman without comorbidity: a case report
© Tokui et al.; licensee BioMed Central Ltd. 2012
Received: 16 February 2012
Accepted: 8 June 2012
Published: 31 August 2012
Chronic necrotizing pulmonary aspergillosis usually occurs in mildly immune-compromised hosts or those with underlying pulmonary disease. The radiographic pattern of chronic necrotizing pulmonary aspergillosis is typically a progressive upper lobe cavitary infiltrate with pleural thickening. We report here an atypical case of chronic necrotizing pulmonary aspergillosis mimicking lung cancer, which developed into a disseminated fatal disease in an older woman with no comorbidity.
An 80-year-old Japanese woman was referred to our hospital for a chest roentgenogram abnormality. Repeated fiber-optic bronchoscopy could not confirm any definite diagnosis, and she refused further examinations. Considering the roentgenogram findings and her age, she was followed-up as a suspected case of lung cancer without any treatment. Then, 10 months later, she complained of visual disturbance and was admitted to our department of ophthalmology. She was diagnosed as having endophthalmitis. After treatment with corticosteroids for 20 days, she developed acute encephalitis and died four weeks later. Autopsy revealed dissemination of Aspergillus hyphae throughout her body, including her brain.
In older patients, even if they do not have any comorbidity, chronic necrotizing pulmonary aspergillosis should be added to the differential diagnosis of solitary pulmonary lesions in a chest roentgenogram.
Aspergillus causes a variety of clinical syndromes in the lung, such as aspergilloma, chronic necrotizing pulmonary aspergillosis (CNPA), invasive pulmonary aspergillosis and allergic bronchopulmonary aspergillosis . Aspergilloma occurs in patients with lung cavities, CNPA occurs in those who are mildly immunocompromised and invasive pulmonary aspergillosis is seen in patients who are immunocompromised, such as those with leukemia. We report a case of an older woman with a tumor-like shadow in her chest roentgenogram, which developed into disseminated invasive aspergillosis after 10 months of follow-up.
The disease type associated with Aspergillus infection depends on the host’s immunological status. Invasive pulmonary aspergillosis usually occurs in immunocompromised hosts, such as patients with leukemia, and is rapidly progressive . The predisposing factors for CNPA development are mildly immunocompromised status or underlying lung diseases, such as chronic obstructive pulmonary disorder (COPD), inactive tuberculosis and pneumoconiosis [3, 4]. CNPA is usually a chronic, indolent and localized form of Aspergillus infection . Our patient’s case was compatible with this category, but was not typical in two regards. First, our patient did not have any underlying lung disease. Second, she developed disseminated fatal disease in the course of CNPA. We speculate that her age contributed to the disease. Cornet et al. reported two cases of fulminant invasive pulmonary aspergillosis in immunocompetent but older patients . Two patients received short-term systemic corticosteroid therapy and their invasive aspergillosis progressed rapidly. The authors speculated that old age may have been a predisposing factor for the onset and rapidly fatal outcome of invasive aspergillosis. It should be highlighted that very old age might be a predisposing factor of CNPA. Two groups in Korea reported pulmonary aspergillosis in immunocompetent hosts without underlying lung disease [7, 8]. According to these authors, radiographic findings presented as a nodule or mass that could not be differentiated from malignancy on CT scan. Similarly, the radiographic findings in our patient’s case mimicked lung cancer. The image of another case of invasive aspergillosis was also reported to mimic lung cancer . Because lung cancer is far more prevalent than aspergillosis, the latter might be easily misdiagnosed as lung cancer. Because anti-fungal treatments have improved recently , an appropriate diagnosis and early treatment of CNPA are particularly important for a better outcome.
A tumor-like shadow in a chest roentgenogram can be caused by CNPA in older people with no comorbidity. It should be borne in mind that very old age might itself be a predisposing factor for CNPA. Observation without appropriate treatment and even short-term corticosteroid therapy might lead to acute fatal disseminated aspergillosis. It is important to undertake careful examination and observation of undiagnosed pulmonary nodular or mass lesions because CNPA can be hidden in older patients.
Written informed consent was obtained from the patient’s next of kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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