Allergic Bronchopulmonary Aspergillosis with Repeated Isolation of Nontuberculous Mycobacteria

Abstract

A 68-year-old woman without asthma presented with a cough and abnormal shadows on a chest X-ray. Computed tomography showed right middle lobe atelectasis and centrilobular nodules with a tree-in-bud appearance in the other lobes. The patient's sputum repeatedly yielded positive cultures of nontuberculous mycobacteria (NTM); however, no fungi were detected. A transbronchial biopsy showed allergic mucin with eosinophils, although the findings were not diagnostic. We suspected that the patient had pulmonary mycobacteriosis; however, treatment for this condition failed. We then performed thoracoscopy for further evaluation and treatment of the NTM infection. The resected specimen obtained from the right middle lobe exhibited the characteristic findings of allergic bronchopulmonary mycosis without evidence of mycobacterial infection. The administration of corticosteroids and itraconazole resulted in improvement of the patient's condition. The NTM appeared to be simply a coincidental colonization of the resected middle lobe bronchus. The absence of asthma, the inability to isolate fungi and the repeated isolation of NTM made it difficult to differentiate allergic bronchopulmonary aspergillosis from NTM infection.

Clinical Characteristics of Biopsy-proven Allergic Bronchopulmonary Mycosis: Variety in Causative Fungi and Laboratory Findings

“…Four of these cases have been previously reported (6,7,9,10). Two patients yielded A. fumigatus (9) and A. niger (10) from the sputum only; serum precipitating antibodies and specific IgE for each fungus were positive in these patients, and each fungus was regarded as causative. Significant fungi were not isolated in the other patients.…”

Pulmonary Nontuberculous Mycobacteriosis and Chronic Lower Respiratory Tract Infections in Patients with Allergic Bronchopulmonary Mycosis without Cystic Fibrosis

“…One patient who was reported previously was included (7). In that patient, isolated NTM were regarded as colonization in 2009; however, the patient developed pNTM (Mycobacterium avium complex) in 2014.…”

“…Previous reports by Mussaffi et al (2), Levy et al (11), and Kunst et al (15), and our results suggest that systemic corticosteroid therapy may be responsible for pNTM. Previously, we reported one patient in whom NTM was repeatedly isolated, and the histologic samples obtained via right middle lobe resection showed findings of ABPM (7). Because pulmonary shadows suggestive of pNTM had not developed and NTM had not been isolated for several years, the presence of NTM was regarded as colonization.…”

Omalizumab, an additional therapy for allergic bronchopulmonary aspergillosis

“…Some case studies in which ABPA was treated with lobectomy noted that oral steroids were needed even after resection. 7,8 One case with a 2-year follow-up showed resolution of symptoms and radiographic opacities after resection; however, the patient was not treated initially with antifungals or oral steroids and might have responded to these therapies before surgery. 8 Other case reports have shown a favorable surgical outcome in localized ABPA.…”

“…7,8 One case with a 2-year follow-up showed resolution of symptoms and radiographic opacities after resection; however, the patient was not treated initially with antifungals or oral steroids and might have responded to these therapies before surgery. 8 Other case reports have shown a favorable surgical outcome in localized ABPA. These patients required no oral steroids after resection, but their follow-up was limited or not mentioned in the case report.…”