Presentation
New onset dyspnea and mucus expectoration, with no fever in a severely neutropenic hospitalized patient undergoing capecitabine adjuvant treatment for rectal neoplasia.
Patient Data
New onset bilateral ill-defined patchy opacities of right perihilar and central predominance.
Bilateral patchy bronchocentric consolidation with ground-glass haloes.
Central predominant bronchial wall thickening, bronchiectasis and distal luminal narrowing.
Upper zone predominant centrilobular emphysema.
Case Discussion
Our patient was hospitalized due to severe toxicity secondary to capecitabine treatment, including renal, mucosal, gastrointestinal and bone marrow toxicity. He suffered from pancytopenia with severe neutropenia (<100 Absolute Neutrophil Count - ANC). In previous days he underwent analgesic treatment, which also had antipyretic effects.
In this case, CT findings were highly suspicious for a bronchopneumonic process, with fever probably obscured by analgesics. Even though these features are highly nonspecific, one should first raise concern for bacterial etiology. Given the patient context, less common causes such as fungal infections should be considered.
Bronchoscopy showed partial lobar bronchi obstruction by white pseudomembranous exophytic lesions, along with edematous friable bronchial mucosa. Bronchoalveolar lavage (BAL) offered positivity for galactomannan antigen and Aspergillus spp. was isolated from respiratory secretions. Serum galactomannan antigen was also positive. It should be noted that Pneumocystis jiroveci was also isolated from respiratory secretions, although radiological findings are not characteristic.
Overall, imaging findings, clinical context, bronchoscopy, BAL and serum results offered an almost certain diagnosis for aspergillus bronchopneumonia, a form of airway invasive aspergillosis.
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