Immune reconstitution syndrome (mucous impaction or obstructing bronchial aspergillosis) complicating pulmonary aspergillosis in AIDS

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This 58 year old man with AIDS (CD4+ count 5ul/L) presented with weight loss and pneumocystis pneumonia. He was treated with adjunctive corticosteroids. After 14 days a new round shadow that later cavitated appeared in his right upper lobe. This progressed over the next month and the left upper lobe was also affected. A biopsy revealed hyphae consistent with Aspergillus and his sputum grew A. fumigatus, Concurrent treatment with amphotericin B and HAART were started, with little change. Itraconazole was also unsuccessful.
 He developed a pleural effusion and a repeat BAL culture grew A. fumigatus. He was switched to voriconazole as his CD4+ cell count had increased to 340/ml. He then developed fever spikes, increasing opacity of both lungs on chest radiograph and started coughing up thick sputum. He became increasingly hypoxic with almost complete opacification of his left lung. He died and an autopsy revealed extensive bilateral mucous plugging of airways and trachea, with bilateral pulmonary cavities showing invasive aspergillosis.

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Case history