We report a case of noninvasive pulmonary disease due to Chrysosporium zonatum in an immunocompetent male. The fungus colonized an existing tuberculous cavity and was isolated from transbronchial lavage fluid and from a percutaneous aspiration specimen. The disease was accompanied by the unusual feature of an allergic reaction. The fungus ball was successfully treated by intracavitary administration of amphotericin B. C. zonatum is the anamorph of the heterothallic ascomycete Uncinocarpus orissi, and the identity of the case isolate was verified by formation of ascospores in mating tests with reference isolates.
CASE REPORTA 72-year-old man initially visited another hospital complaining of a productive cough and fever in December of 1995. He had experienced pulmonary tuberculosis 10 years earlier.Previous chest X-rays revealed thin wall cavities in the right upper lobe (RUL), but otherwise he was in good health. Changes in the chest X-rays, i.e., thickened cavity walls with airspace consolidation in the RUL, suggested the presence of a bacterial infection. However, bacteriological cultures of blood and sputum specimens were negative. The patient failed to respond to empirical antibiotic therapy with clindamycin and imipenem and developed dyspnea. At admission to Saga Medical School Hospital on 25 January 1996, chest X-rays and computed tomography (CT) revealed enlarged cavities, in one of which an air-fluid level was noted, in the RUL. Bilateral mixed airspace and interstitial infiltrations, distributed mainly in the right lower lobe (RLL), were also observed. An increase in eosinophils was noted in peripheral blood (around 900/l) and in bronchoalveolar lavage (BAL) fluid from the RLL (14%). Histopathological examination of transbronchial lung specimens from the RLL indicated interstitial infiltration of numerous lymphoplasmacytoid cells and smaller numbers of neutrophils and eosinophils. No organisms were detected by periodic acid-Schiff and Ziehl-Neelsen staining. As his clinical symptoms and pulmonary infiltrations worsened, peripheral eosinophils were elevated to 2,600/l, suggesting involvement of an allergic process. Corticosteroid therapy was started on 20 February. Consequently, the symptoms subsided and the diffuse infiltrations and air-fluid level in the cavity diminished. A follow-up CT scan revealed a homogeneous round mass suggestive of a fungus ball in one of the cavities (Fig. 1). While receiving oral prednisolone at 10 mg/day, the patient developed a mild fever and an intermittent productive cough. Because the clinical course resembled allergic bronchopulmonary aspergillosis, oral itraconazole (ITRA), 100 mg/day, was added on 22 March.Specimens were collected by BAL on 19 March and CTguided percutaneous needle aspiration on 10 April and sent for microbiological analysis. Microscopic observations of gramand Giemsa-stained specimens were negative for hyphae. The samples were cultured on sheep blood agar at 35°C for 2 days and Sabouraud dextrose agar (Difco Laboratories, Detroit, Mich.) at 30°C for 7...