|Year : 2020 | Volume
| Issue : 2 | Page : 267-270
A rare case report of allergic bronchopulmonary aspergillosis with active pulmonary tuberculosis
Deependra Kumar Rai1, Sudhir Kumar2, Subhash Kumar3
1 Department of Pulmonary Medicine, Chest Superspeciality Hospital, Patna, Bihar, India
2 Director, Ramkrishna Chest Superspeciality Hospital, Patna, Bihar, India
3 Department of Radiology, AIIMS Patna, Bihar, India
|Date of Submission||20-Jul-2020|
|Date of Decision||04-Aug-2020|
|Date of Acceptance||06-Oct-2020|
|Date of Web Publication||23-Dec-2020|
Dr. Deependra Kumar Rai
Additional Professor & Head, Department of Pulmonary Medicine, AIIMS, Patna, Bihar
Source of Support: None, Conflict of Interest: None
Allergic bronchopulmonary aspergillosis (ABPA) is a disorder caused by a hypersensitivity reaction to antigens of Aspergillus fumigatus and is commonly seen in patients suffering from bronchial asthma or cystic fibrosis. ABPA in patients with active pulmonary tuberculosis a rare finding because tuberculosis, being very common in this part of the world, often masks the clinical features of ABPA. A high index of suspicion is thus necessary to confirm the presence of the latter in patients with atypical presentations. We wish to report two such cases, in which ABPA was diagnosed while the patient was receiving anti-tubercular therapy.
Keywords: Acid-fast bacilli, allergic bronchopulmonary aspergillosis, pulmonary tuberculosis
|How to cite this article:|
Rai DK, Kumar S, Kumar S. A rare case report of allergic bronchopulmonary aspergillosis with active pulmonary tuberculosis. Arch Med Health Sci 2020;8:267-70
|How to cite this URL:|
Rai DK, Kumar S, Kumar S. A rare case report of allergic bronchopulmonary aspergillosis with active pulmonary tuberculosis. Arch Med Health Sci [serial online] 2020 [cited 2021 Apr 11];8:267-70. Available from: https://www.amhsjournal.org/text.asp?2020/8/2/267/304713
| Introduction|| |
Hypersensitivity to antigens of the Aspergillus fumigatus is the main etiology behind allergic bronchopulmonary aspergillosis (ABPA). It is most commonly described in patients suffering from bronchial asthma or cystic fibrosis., In a developing country like India, pulmonary tuberculosis (PTB) caused by infection of Mycobacterium tuberculosis (MTB) forms the majority of clinical cases seen in pulmonary medicine specialty. ABPA is commonly suspected in patients with a previous history of PTB and ABPA is commonly misdiagnosed as PTB.,, True concomitant ABPA with active PTB is extremely rare and has rarely been reported in the literature. We wish to report two cases we encountered, where ABPA was confirmed in patients with active tuberculosis.
| Case Reports|| |
A 38-year-old, nonsmoking woman presented with complaints of productive cough with whitish expectoration, modified Medical Research Council Grade 3 breathlessness, fever, and loss of appetite for the past 2 months. She denied any history for hemoptysis, significant weight loss, wheeze, or history of anti-tubercular treatment (ATT). The patient had been prescribed inhaled asthma medications and oral prednisolone 20 mg per day by a general physician 5 days back. On examination, the patient was afebrile, had a heart rate of 102 beats per minute, respiratory rate of 22 breaths per minute, blood pressure of 112/72 mmHg, and oxygen saturation of 94% on room air. Examination of the respiratory system revealed normal breath sounds, polyphonic wheezing, inspiratory, and expiratory crackles in the right infraaxillary area. General physical and other systemic examinations were unremarkable. A chest radiograph showed infiltrates and consolidation-collapse in the right upper lobe [Figure 1]a. High-resolution computed tomography (HRCT) scan of the thorax showed centrilobular nodules with tree-in-bud appearance and consolidation in the right upper lobe [Figure 1]b,[Figure 1]c,[Figure 1]d. The patient was provisionally diagnosed as a case of bronchial asthma with community-acquired pneumonia and treated with oral cefpodoxime 200 mg twice a day, inhaled budesonide 400 μg with formoterol 2 puffs twice a day, and inhaled salbutamol as and when required. Hematological investigations revealed hemoglobin 9.8 g%, total leukocyte count 11,300/mm3, neutrophil 69.6%, lymphocyte 18.5%, and eosinophil 5.3%. Sputum examination for gram stain was negative, and the culture did not grow any bacteria. However, the sputum was positive for acid-fast bacilli (AFB) (2+), and the GeneXpert, a cartridge-based nucleic acid amplification test, detected MTB which was rifampicin sensitive. The sample could not be processed for MTB culture because it was not available. The patient was put on ATT with four first-line drugs, rifampicin, isoniazid, ethambutol, and pyrazinamide, according to body weight. After a month, when the sputum had turned negative for AFB, spirometry was performed which showed mild obstructive features-forced expiratory volume in 1st s (FEV1) of 1.37 L and forced vital capacity (FVC) of 2.09 L (values being 60.0% and 79% of the predicted values, respectively) with the FEV1/FVC ratio being 65.6% with nonsignificant bronchodilatation 90 mL (7%) after 400 mcg of salbutamol inhalation. A diagnosis of sputum positive PTB with bronchial asthma was made. Although the patient had turned afebrile, she continued to have a sleep-disturbing cough. The combination of persistent chest symptoms, eosinophilia, and asthma raised suspicion of ABPA, and the patient was evaluated for the same. The total serum immunoglobulin E (IgE) level estimated using a fully automated chemiluminescence system was found to be 1976 IU/mL (normal level <100 IU/mL). Serum levels of specific IgE against A. fumigatus were 0.82 kU/L (normal level <0.1 kU/L). Previous investigation records also showed peripheral blood eosinophilia (absolute eosinophilia count 950). Applying the International Society for Human and Animal Mycology criteria, the patient was thus also confirmed to have ABPA. The patient was continued on ATT with inhaled corticosteroid and long-acting beta-agonist for asthma. She was also given oral prednisolone at a dose of 0.75 mg/kg once a day for 6 weeks, 0.5 mg/kg for the next 6 weeks, then tapered by 5 mg every 6 weeks for a total duration of 6 months. The serum total IgE levels dropped to 213 IU/mL in four months' time and a chest radiograph performed after 6 months showed complete clearance of the radiopacities, with the presence of some fibrosis in the right upper lobe [Figure 2]. The patient was continued on inhaled budesonide 400 μg with formoterol in two divided doses and inhaled salbutamol as and when required.
|Figure 1: (a) Chest radiograph posteroanterior showing infiltrates and consolidation-collapse in the right upper lobe; metallic bra clips are seen on either side (b) high-resolution computed tomography chest, showing consolidation of the right apical lung with multiple calcifications within, a right paratracheal node is seen (white arrow) (c) high resolution computed tomography axial section, lung window, just below carina, showing centrilobular nodules with a tree in bud appearance and consolidation in right lower lobe (dashed circle) (d) high resolution computed tomography at slightly lower level, showing peribronchovascular consolidation and nodules with surrounding ground glass opacities and a small cavity (black arrow)|
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A 21-year-old, nonsmoker, male student presented with excessive dry cough, leading to breathlessness at rest, and occasional vomiting. He gave a history of recurrent fever (maximum 101F), anorexia, and weight loss of 5 kg in the past 2 months. The patient had been put on ATT for the past 1 month on a clinicoradiological basis, but without any improvement. On examination, the patient was afebrile with a heart rate of 88 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 124/70 mmHg, and oxygen saturation of 97% at room air. Examination of the respiratory system revealed normal breath sounds along with polyphonic wheezing as well as inspiratory and expiratory crackles in the left infra axillary area. General physical and other systemic examinations were unremarkable. A chest radiograph showed collapse-consolidation in the left upper lobe [Figure 3]a. Video-bronchoscopy showed mucopurulent secretions in the left upper lobe with inflamed and edematous bronchial mucosa. Bronchoalveolar lavage (BAL) was taken and sent for GeneXpert, AFB, and fungal culture. GeneXpert detected the presence of rifampicin sensitive MTB. BAL fluid did not grow fungus but demonstrated growth of MTB after 3 weeks of incubation. The culture was also subjected to a drug sensitivity test which shows MTB sensitivity to all first-line drugs. The patient was continued on ATT which he had been receiving for the past 1 month. Despite 2 months of ATT, the patient continued to have symptoms of cough and breathlessness, although fever had subsided. Chest radiograph also did not show significant improvement [Figure 3]b. Fiberoptic bronchoscopy showed mucopurulent secretions in the left upper lobe bronchus, but there was no history of expectoration from the patient. This suggested presence of tenacious secretions blocking the left upper lobe bronchus and suspicion of ABPA was aroused.
|Figure 3: Serial imaging, (a) chest radiograph posteroanterior view, prior to commencement of anti-tubercular treatment, showing consolidation in the left upper and mid zones (b) radiograph after two months of treatment showing improvement in the consolidation in the left upper and midzone (c) high-resolution computed tomography scan, lung window, and (d) soft-tissue window, showing left upper lobe collapse-consolidation (star), and few centrilobular nodules with tree in bud appearance, slightly posteriorly (white dashed oval outline) (e) Chest radiograph showing a fibrotic lesion in the left upper zone; the multiple oval bright radiopacities in images b and e are artifacts|
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Blood examination showed an absolute eosinophil count of 650. The total serum IgE level estimated using a fully automated chemiluminescence system was 2728 IU/mL (normal level < 100 IU/mL). Specific IgE level against A. fumigatus was 0.17 kU/L (normal level <0.1 kU/L) and serum specific IgG level was 63.4 mg/L (normal level <27.0). Spirometry demonstrated moderate obstruction without significant postbronchodilator reversibility (postbronchodilator FEV1 57% of predicted with a 37% increase in FEV1) suggestive of bronchial asthma with persistent airflow limitation. HRCT scan showed left upper lobe collapse-consolidation with centrilobular nodule and tree-in-bud formation [Figure 3c and d]. Along with ATT, this patient was also put on the same regimen as the first case, i.e., prednisolone at a dose of 0.75 mg/kg once a day for 6 weeks, 0.5 mg/kg for the next 6 weeks, then tapered by 5 mg every 6 weeks for a total duration of 6 months. He was also prescribed inhaled budesonide 200 μg with formoterol 2 puffs twice a day and inhaled salbutamol as and when required. After 6 weeks of treatment, improvement in chest X-ray was evident [Figure 3e]. The patient was continued on the same treatment and he has been doing well during follow-up.
| Discussion|| |
These cases highlight possible coexistence of ABPA in patients suffering from active PTB. Aspergillus is a saprophytic fungus, widely distributed in the environment and transmission occurs through inhalation of their spore. The association between Mycobacterium infection and Aspergillus has been a subject of interest for researchers. A study reported that in positive tuberculosis patients, up to 12.3% had coinfection of TB with fungi microorganisms. They also showed A. fumigatus as the most common species. Colonization of posttubercular lung cavities by Aspergillus to produce fungal balls is a well-known phenomenon. ABPA is frequently wrongly label as PTB as the patients can have similar and overlapping clinical and radiological manifestations. It has been found that almost one-third to half of all patients with ABPA may have received ATT before the ABPA could be diagnosed., ABPA predominantly occurs in patients with asthma and cystic fibrosis. Its prevalence in other chronic respiratory diseases such as chronic obstructive pulmonary disease or bronchiectasis is not known. ABPA is well described in previously treated PTB patients but rarely reported in patients with active PTB. The authors could find two other cases in the literature., One case was sputum negative for AFB but culture and GeneXpert positive, while the other case had shown AFB and polymerase chain reaction positivity in a biopsy sample.
Our cases are unique because they are probably the first reports of sputum positive PTB with ABPA. We are not sure, however, whether the coexistence of both conditions represents a true association. It could be a mere coincidence because normally Th1 response against MTB infection inhibits the Th2 response and reduces risk of development of allergy and asthma. After treatment, the Th1 responses fall and there is relatively predominance of Th2 response with increased risk of asthma and ABPA.
It is very important to rule out PTB while evaluating ABPA, especially in a country like India where tuberculosis infection is endemic. Our second case highlights the fact that ABPA coinfection should be kept as a possible diagnosis in patients with active PTB who are not responding to ATT.
| Conclusion|| |
These cases highlight a need for heightened suspicion and careful evaluation to rule out the coexistence of ABPA and PTB even in patients with active PTB.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tillie-Leblond I, Tonnel AB. Allergic bronchopulmonary aspergillosis. Allergy 2005;60:1004-13.
Nowicka U, Wiatr E, Jakubowska L, Polubiec-Kownacka M. Allergic bronchopulmonary aspergillosis mimicking lung cancer in a non-asthmatic female patient: A case report. Pneumonol Alergol Pol 2012;80:77-81.
Boz AB, Celmeli F, Arslan AG, Cilli A, Ogus C, Ozdemir T. A case of allergic bronchopulmonary aspergillosis following active pulmonary tuberculosis. Pediatr Pulmonol 2009;44:86-9.
Agarwal R, Singh N, Aggarwal AN. An unusual association between Mycobacterium tuberculosis
and Aspergillus fumigatus
. Monaldi Arch Chest Dis 2008;69:32-4.
Agarwal R, Gupta D, Aggarwal AN, Behra D, Jindal SK. Allergic bronchopulmonary aspergilosis: Lessons from 126 patients attending a chest clinic in North India. Chest 2006;130:442-8.
Agarwal R, Aggarwal AN, Dhooria S, Singh Sehgal I, Garg M, Saikia B, et al
. A randomised trial of glucocorticoids in acute-stage allergic bronchopulmonary aspergillosis complicating asthma. Eur Respir J 2016;47:490-8.
Amiri MR, Siami R, Khaledi A. Tuberculosis status and coinfection of pulmonary fungal infections in patients referred to reference laboratory of health centers Ghaemshahr city during 2007-2017. Ethiop J Health Sci 2018;28:683-90.
Caidi M, Kabiri H, Al Aziz S, El Maslout A, Benosman A. Surgical treatment of pulmonary aspergilloma. 278 cases. Presse Med 2006;35:1819-24.
Al-Moudi OS. Allergic bronchopulmonary aspergillosis mimicking pulmonary Tuberculosis. Saudi Med J 2001;22:708-13.
Behera D, Guleria R, Jindal SK, Chakrabarti A, Panigrahi D. Allergic bronchopulmonary aspergillosis: A retrospective study of 35 cases. Indian J Chest Dis Allied Sci 1994;36:173-9.
Greenberger PA. Allergic bronchopulmonary aspergillosis. J Allergy Clin Immunol 2002;110:685-92.
Min KH, Park SJ, Kim SR, Lee MH, Chung CR, Han HJ, et al
. Coexistence of allergic bronchopulmonary aspergillosis and active pulmonary tuberculosis. Am J Respir Crit Care Med 2011;183:137-9.
Purohit S, Joshee V. A rare case of coexistence of allergic bronchopulmonary aspergillosis (ABPA) and active pulmonary tuberculosis- Role of CBNAAT in ABPA evaluation. Indian J Tuberc 2019;66:418-9.
Jones PD, Gibson PG, Henry RL. The prevalence of asthma appears to be inversely related to the incidence of typhoid and tuberculosis: Hypothesis to explain the variation in asthma prevalence around the world. Med Hypotheses 2000;55:40-2.
Rajasekaran S, Savithri S, Jeyaganesh D. Post-tuberculosis bronchial asthma. Ind J Tub 2001;48:139-42.
[Figure 1], [Figure 2], [Figure 3]