Allergic Broncho-Pulmonary Aspergillosis

Case History: A 60-year-old female presents with the complaint of breathlessness during rest, which increases on supine position and in rainy weather, not associated with smoke and dust; cough with non-purulent non-blood stained whitish expectorant; and fever. She is a known case of bronchial asthma and hypothyroidism. Patient is a retired teacher by occupation. Sputum microscopy is negative for acid fast bacilli and other micro-organisms. Upon laboratory investigation, there is peripheral eosinophilia and positive IgM antibody for aspergillus fumigates.

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Figure 1. Chest X-Ray shows multiple fleeting radiopacities in right upper lobe and dense tube-like soft tissue opacity extends from hilum of right lung to outwards in right upper lobe giving finger in glove appearance.

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Figure 2. HRCT scan revealed extensive central cystic bronchiectasis filled with high density mucus material involving right upper lobe (finger in glove appearance; arrow) and postero-basal segment of bilateral lower lobes. Multiple tiny nodules in bilateral lung fields, predominantly in upper lobes, with few of them showing peripheral tree in bud appearance. No evidence of mediastinal lymphadenopathy and pleural effusion, findings are suggestive of allergic broncho-pulmonary aspergillosis.

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Figure 3. CT (mediastinal window) showed multiple tubular structures filled with high density mucus material involving right upper lobe (finger in glove appearance; arrow) and postero-basal segment of bilateral lower lobes. No evidence of mediastinal lymphadenopathy and pleural effusion.

Diagnosis: Allergic broncho-pulmonary aspergillosis (ABPA)

Discussion: Aspergillus species are ubiquitous spore-forming fungi present in the environment, the one most commonly affected by humans is Aspergillus fumigates. Clinical presentation occurs in various forms, from active infection in locally destructive disease, or in the most severe form, bronchial wall thickening central bronchiectasis, mucoid impaction, tubular branching pattern of mucoid impaction giving a finger in glove appearance and no pleural effusion or adenopathy, tree in bud abnormality, migratory fleeting opacities and pulmonary disseminated infection in immunocompromised patients. ABPA is a hypersensitive reaction to Aspergillus mycelia that colonize the bronchi. Asthma and cystic fibrosis are common illnesses associated with ABPA. The prevalence of ABPA is reported to be 1 percent to 2 percent in asthmatics, 7 percent to 14 percent in steroid-dependent asthmatics, and 2 percent to 15 percent in cystic fibrosis. The most common misdiagnosis is TB due to the striking radiological similarity between ABPA and TB, resulting in the patient being treated with anti-TB drugs for a long period of time. The myco-serological tests, peripheral eosinophilia and anti IgM antibody to fungal antigen and radiological investigations like chest X-Ray and CT scan are required.

The chest X-Ray showed dense tube-like soft tissue opacity extends from hilum of right lung to outwards in right upper lobe giving finger in glove appearance and further confirmation by HRCT scan which revealed extensive central cystic bronchiectasis filled with high density mucus material involving right upper lobe and postero-basal segment of bilateral lower lobes. Multiple tiny nodules in bilateral lung fields, predominantly in upper lobes, with few of them showing tree in bud appearance. No evidence of mediastinal lymphadenopathy and pleural effusion.

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