A Rare Case of Chronic Invasive Pulmonary Aspergillosis

Abstract

Invasive pulmonary aspergillosis (IPA) and invasive aspergillosis (IA) are two examples of the broad clinical spectrum of Aspergillus infection. It mainly affects severely immunocompromised hosts, while immunocompetent people can sometimes be affected, especially those receiving treatment in the intensive care unit (ICU) for emergency cases with few instances of chronic cases. The risk factors in ICU patients for aspergillosis include intubated patients receiving hot and humidified air, viral infections like covid, and influenza, and diseases like diabetes, chronic obstructive pulmonary disease, etc. A case of 35-year-old male reported to us with a complaint of stomach discomfort that was acute and non-progressive in the epigastric area, radiating to the back, not accompanied by fever, and not linked with loose stools/vomiting. In addition, the patient experienced a nonproductive cough for two days that was not associated with dyspnea or chest discomfort. He had a high-resolution computed tomography (HRCT) thorax, which revealed a single pulmonary nodule in the left lung's middle zone; histology of the same nodule biopsy material revealed that it was caused by Aspergillus. He had an abdominal ultrasound, which revealed portal vein thrombosis, dilated periportal tortuous veins, evident peri splenic and mesenteric collaterals, and significant splenomegaly - suggestive of portal cavernoma formation with chronic liver parenchymal disease. Our patient has a past history of alcohol use disorder for the last 15 years due to which the patient has had recurrent episodes of acute pancreatitis for the last three years which has now progressed to chronic pancreatitis, also the patient has been diabetic for the last 10 years on insulin for the same. A patient with multiple comorbidities, such as cirrhotic portal cavernoma, type 2 diabetes, diabetic neuropathy, and acute and chronic pancreatitis, is the subject of our case study on chronic IPA.

Keywords: acute on chronic pancreatitis; chronic invasive pulmonary aspergillosis; idiopathic portal cavernoma; type 2 diabetic mellitus with diabetic neuropathy; young male.

Figure 1. Single ill-defined pulmonary nodule (seen with red arrow) with an irregular spiculated margin showing subtle peripheral post-contrast enhancement with subpleural thickening seen in adjacent pleura in the left lower lobe in the superior segment as seen in this axial CT thorax section.

Figure 2. Solitary pulmonary nodule in the left lower lobe in the superior segment as seen in the current coronal section of CT thorax figure with red arrow.

Figure 3. This CECT abdomen axial section shows the portal vein which is completely replaced by a tuft of dilated tortuous collaterals - cavernoma formation as shown by the red arrow.

CECT: contrast-enhanced computed tomography

Figure 4. This coronal CECT abdomen section shows coarse echotexture of the liver with portal cavernoma formation (as seen with red arrow) with multiple dilated tortuous collaterals in the peri-pancreatic region, peri-gastric region, para oesophageal region, and at splenic hilum.

CECT: contrast-enhanced computed tomography

Figure 5. Multiple slender fungal hyphae with acute angle branching amidst the background of the necrotic area.

Figure 6. On Gomori methenamine stain (GMS) of the same tissue section, it showed brown-coloured fungal hyphae with acute angle branching.

Figure 7. Graphical animated representation of all the comorbidities the patient has which increased the chances of getting aspergillosis which is an opportunistic infection.

Image credits: Dr. Aniket Garud