Date: 26 November 2013
X-Rays -Allergic Bronchopulmonary Aspergillosis (ABPA) with 3 relapses.
A female patient JO (50 yrs) with right middle lobe collapse. The patient presented with a 6 month history of cough which has persisted despite antibiotics and both steroid and salbutamol inhalers. She then developed acute breathlessness with coughing and wheezing. There was no history of asthma. Bronchoscopy (Image K) showed a mucous plug obstructing the right upper lobe bronchus.
Images D – G are X rays showing relapse in 1998 and recovery
Images H – J are X rays showing relapse in 2003
Image K. Bronchoscopy appearance of mucous impaction of the bronchus intermedius – pt JO (50yrs). There was a long mucous plug in the anterior segment of the RUL. Half of this was aspirated and sent for microscopy and culture. The second half “fell into” the bronchus intermedius (which feeds the right middle lobe) and was only partially aspirated.
Images L – O: High resolution CT scan of thorax in pt JO, post bronchoscopy. 1.5mm sections at 1 cm intervals of whole lung. There is collapse and consolidation in the right middle lobe with dilation of the right middle lobe bronchi. There is also minor bronchiectasis in the right upperlobe with a little patchy air space shadowing . There is no mediastinal lymphadenopathy or any interstitial fibrosis.
Image P & Q: Histology: Mucous plug (3x 0.5x 0.5cm) containing numerous inflammatory cells, including eosinophils and nuclear debris.GMS staining reveals occasional fungal hyphae with septa and dichotomous branching. These appearances support the diagnosis of bronchopulmonary Aspergillosis. Bronchioalveolar lavage fluid was negative on microscopy and no fungi were grown. A year later Aspergillus fumigatus was grown from her sputum.
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Drug rashes: Drug interactions between steroids and anti-fungal drugs – (ecchymosis)
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Reference: Muco-cutaneous retinoid effects and facial erythema related to the novel triazole antifungal agent voriconazole. Denning, DW & Griffiths, CEM. Clin.Exp Dermatol 2001, 26(8), 648-53.
Courtesy of Dr D Denning, Wythenshawe Hospital, Manchester.(© Fungal Research Trust), ,
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Micrographs of A. niger conidia & conidial heads provided by Amaliya Stepanova, Head of Laboratory pathomorphology and cytology at Kashkin Research Institute, Russian Federation.
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Micrographs of A. terreus conidia & conidial heads provided by Amaliya Stepanova, , Head of Laboratory pathomorphology and cytology at Kashkin Research Institute, Russian Federation.
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Micrographs of A. fumigatus conidia & conidial heads provided by Amaliya Stepanova, , Head of Laboratory pathomorphology and cytology at Kashkin Research Institute, Russian Federation.
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Patients has history of ABPA complicating long standing asthma. His total IgE has fluctuated between 2,200 and 4,600 KU/L, his Aspergillus IgE between 36.3 and 65.4 kAU/L and Aspergillus IgG from 87-154 mg/L. He has been taking long term itraconazole.
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