An Unusual Cause of Lung and Kidney Mass

Abstract

INTRODUCTION: The most common cause of granulomatous inflammation of lung in India is tuberculosis (TB), other etiologies need to be considered if the clinical scenario is not consistent with TB. We present an unusual cause of granuloma, which remained elusive for over two and half years. CASE PRESENTATION: A 14 year old apparently immunocompetent boy was referred to our center for evaluation of non resolving mass lesion measuring approximately 5 X 3.5 cm diameter in the right paratracheal region. His initial presentation was over two and half years ago when he had cough and fever of one-month duration and detected to have this lesion in course of evaluation. Thoracoscopic biopsy and transbronchial needle aspiration of this lesion on different occasions had revealed granulomatous inflammation for which he had been started on antitubercular therapy (ATT). His constitutional symptoms persisted despite six months of ATT and hence he had also received steroids as possibility of sarcoidosis was considered in view of elevated ACE levels. He continued to lose weight and reevaluation had shown increase in the size of the mass and hence was referred to our center. Endobronchial ultrasound guided transbronchial needle aspiration (EBUSTBNA) from the lesion again revealed granulomatous inflammation and growth of Aspergillus fumigatus on fungal cultures. A computerized tomography (CT) of abdomen and ultrasound abdomen revealed left renal mass consistent with organised abscess, biopsy of which also showed Aspergillus fungal profiles. Serum galactomannan levels were elevated. In light of these developments, slides of thoracoscopic biopsy done at the beginning of evaluation were reviewed which too showed fungal profiles. He was treated with intravenous Voriconazole loading dose for one week and has been started on oral maintenance therapy. After two weeks of oral maintenance therapy his clinical symptoms and mass lesion on chest radiograph started improving. DISCUSSION: Anti-tubercular therapy is commonly prescribed for patients with granulomatous inflammation in India even in the absence of tubercular bacilli in stain or culture which is probably justified in majority of the cases but may not be true in all cases. The diagnosis of Chronic aspergillosis was not initially suspected as the patient was apparently immunocompetent. Chronic pulmonary aspergillosis usually occurs in patients with underlying chronic lung diseases or mildly immunocompromised patients. This patient did not have any obvious risk factors for aspergillosis and Nitrobluetetrazolium test showed neutrophil phagocytic activity comparable to normal individuals. Pulmonary aspergillosis in immunocompetent host without a structural lung disease can manifest with lung mass in the upper lobes and mimicks malignancy. (1 & 2). Renal invasive mold infections usually occur in the setting of renal transplant, HIV or immunosuppressive therapy and is unusual in apparently immunocompetent host. Aspergillosis presenting as kidney mass in unsuspected chronic granulomatous disease has been reported earlier (3).Further elevated serum Galactomannan levels supported the diagnosis of pulmonary and renal aspergillosis in this patient. Concomitant pulmonary and renal aspergillosis has been rarely reported. Histopathologists should be aware of aspergillosis as a cause of granulomatous inflammation and lung mass in the absence of which appropriate fungal stains will not be performed as has happened in this case. A diagnosis of Sarcoidosis requires exclusion of other diseases that may present with noncaseating granulomas. Other causes need diligent exclusion when a patient is not responding and / or the clinical picture is not consistent. CONCLUSION(S): Chronic aspergillosis presenting as lung and kidney mass in apparently immunocompetent host has been rarely reported. Fungal infections need to be considered as a cause of granulomatous inflammation even in tuberculosis endemic countries.