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CASE REPORT
Year : 2022 | Volume
: 11
| Issue : 4 | Page : 460-462
Coexistence of human immunodeficiency virus, active pulmonary tuberculosis, and aspergilloma: A rare entity
Sneha Leo1, Ravindrachari Mulkoju1, Manju Rajaram1, Bheemanathi Hanuman Srinivas2
1 Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Correspondence Address:
Ravindrachari Mulkoju
Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijmy.ijmy_164_22
Tuberculosis (TB) constitutes a significant burden of infectious diseases worldwide. TB and human immunodeficiency virus (HIV) coinfection potentiate each other, which has a negative impact on the disease progression. Aspergillus colonizing a preexisting parenchymal tubercular cavity is referred to as aspergilloma. Aspergilloma occurring in a patient with active TB is unusual. We report the case of a 50-year-old male who presented to us with complaints of cough and recurrent hemoptysis for 3 months. Clinical and radiological examination revealed right upper lobe aspergilloma. A right upper lobectomy was done and a histopathological examination showed evidence of active TB. The patient was started on antitubercular therapy (ATT) followed by antiretroviral therapy (ART). The presence of active TB should not be overlooked in a patient with aspergilloma, especially in immune-compromised individuals such as people living with HIV, as definitive treatment with surgical resection, and ATT along with ART has better outcomes.
Keywords: Aspergilloma, coinfection, human immunodeficiency virus, tuberculosis
Tuberculosis (TB) is a major cause of morbidity and mortality worldwide, with an estimated 10.0 million cases reported annually.[1] People living with human immunodeficiency virus (PLHIV) are 18 times at a higher risk of being infected with TB than their healthier counterparts.[2] The disease has varied pulmonary manifestations, with nearly half of the patients presenting with cavitating lesions as a result of caseating necrosis, the telltale sign of pulmonary TB (PTB). Even after completion of treatment, 20–50% of the patients may have persisting airspace cavities.[3] Saprophytic colonization of this preexisting healed cavity by Aspergillus fungi is called aspergilloma, with Aspergillus fumigatus being the most common species. Aspergilloma complicating active PTB is unusual. Simultaneous active PTB and aspergilloma in a PLHIV patient are even more uncommon and have been rarely reported in the literature and hence the case report.
Case ReportA 50-year-old male, an agricultural laborer by occupation, and a current smoker (smoker index-200) was admitted with complaints of cough and recurrent hemoptysis (mild to moderate) for the past 3 months. He also experienced a loss of appetite and loss of weight. Two years back, he was diagnosed to have microbiologically confirmed PTB, treated with 6 months of antituberculosis therapy (ATT), and was declared cured at the end of treatment. He had no other known comorbidities. General examination was unremarkable. A respiratory system examination revealed bronchial breath sounds and coarse crepitations in the right infraclavicular area.
Baseline blood investigations hemogram showed hemoglobin – 11.5g/dl, WBC counts – 11,500cells/microL, renal function tests, and liver functions tests were within normal range. Virology screening revealed HIV positive with a CD4 count of 340/mm3. Sputum acid-fast bacilli smear and cartridge-based nucleic acid amplification test for Mycobacterium TB (MTB) were negative, and pyogenic and fungal cultures were sterile. Chest X-ray showed right upper zone nonhomogenous opacities. Computed tomography (CT) scan of the chest unveiled an “air crescent sign” with a right upper lobe thick-walled cavity, and intracavitary soft-tissue density rounded mass suggestive of aspergilloma [Figure 1]a and [Figure 1]b.
Figure 1: (a and b) Computed tomography scan of the chest showing “air crescent sign” in the right upper lobe suggestive of aspergillomaIn view of recurrent hemoptysis and the presence of a fungal ball, right upper lobectomy was done through right parasternal thoracotomy. The postoperative period was uneventful. Surgical resection specimen histopathological examination showed extensive areas of caseous necrosis, giant cell reactions with epithelioid histiocytes, and dense inflammatory infiltrates forming lymphoid aggregates indicative of active TB [Figure 2]. Sections from the cavity wall also revealed extensive necrosis with numerous entangled fungal hyphae, which were long, slender, and septate with acute angle branching consistent with aspergilloma [Figure 3]. Tissue sections subjected to mycobacterial culture grew MTB with no resistance on drug susceptibility testing. He was registered and initiated on ATT under National TB Elimination Program. Antiretroviral therapy (ART) was started 2 weeks after initiating ATT. The patient is on regular follow-up.
Figure 2: Histopathological section showing extensive areas of caseous necrosis, giant cell reactions with epithelioid histiocytes, and dense inflammatory infiltrate forming lymphoid aggregates
Figure 3: Histopathological section from the cavity wall showing extensive necrosis with numerous entangled long slender septate fungal hyphae with acute angle branching Discussion Aspergilloma is a fungal ball that develops within a preexisting pulmonary cavity (secondary). In high TB burden countries, TB cavity is the predisposing factor for 90% of aspergilloma cases. The fungal ball is usually composed of mycelial elements, fibrin, mucus, debris, and inflammatory cells. About 11%–17% of patients with post-TB cavities have been reported with aspergilloma.[4] However, aspergilloma may also complicate other cavitating pulmonary diseases such as sarcoidosis, bronchial cysts, bronchiectasis, ankylosing spondylitis, rheumatic nodules, pulmonary infarction, and other pulmonary infections such as pneumonia, lung abscess, and histoplasmosis.
The majority of the patients with aspergilloma are asymptomatic and diagnosed incidentally on chest imaging. Symptomatic patients usually present with hemoptysis. Diagnosis is made based on radiographic features. A solitary lesion in the upper lung fields is the most common radiographic feature. CT scan of the chest reveals an intracavitary rounded mass, surrounded by a crescent of hyperlucency (air crescent sign). The mass may be mobile (Monod's sign) or adherent to the surrounding cavity wall. Serology tests for antibodies to Aspergillus antigens or microbiological evidence may be used to aid the diagnosis.
To date, there is no consensus or recommendation on the management of aspergilloma. For symptomatic patients, surgical resection of the affected lobe is curative; however, it is associated with significant morbidity and mortality. Other treatment options are bronchial artery embolization[5] systemic and local instillation of antifungals. Oral itraconazole has been shown to have better tissue penetration and activity against Aspergillus. However, these are not curative, and patients may present with recurrent symptoms.
Although aspergilloma coexisting in a patient with active TB is rare, there are a few case reports. The largest series of aspergilloma-complicating active PTB was published by Adeyemo et al.[6] Sharma et al.[7] reported a case of a diabetic male with coexisting leprosy, aspergilloma, and active TB, who was managed conservatively with ATT for TB, multidrug therapy for leprosy, and itraconazole for aspergilloma. To the best of our knowledge, there is only one case report of concomitant aspergilloma and active TB in an HIV patient, who was managed conservatively with ATT, ART, and itraconazole.[8]
HIV increases the risk of TB in all stages of the disease irrespective of the CD4 counts. HIV and TB coinfection is associated with increased morbidity and mortality owing to poor containment, delay in diagnosis due to atypical presentation, and high rates of drug-resistant TB. However, this dangerous combination is curable with prompt initiation of ATT and ART. Our patient was diagnosed with aspergilloma by clinical features and radiology, following which he underwent surgical resection followed by evaluation of the resected tissues that helped us establish the final diagnosis. He was treated with ATT for TB and ART for HIV infection, and the patient is healthy to date. Hence, the workup for active TB should be included in the evaluation of patients with aspergilloma, especially those immunocompromised, as definitive treatment will evade a complicated clinical course.
Declaration of patient consent
The authors certify that we have obtained the appropriate patient consent form. In the form, the patient has given his assent and consent for the images and other clinical information to be reported in the journal. He understands that his name and initials will not be published and due efforts will be made to conceal his identity. Further, there is no ethical concern raised in the present case report.
Ethical issues
There is no ethical concern raised in the present case report.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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