Coexistence of Nontuberculous Myocbacteria and Aspergilloma in a 62-Year-Old Female With Hemoptysis

Abstract

INTRODUCTION: In the Philippines, tuberculosis (TB) due to its endemicity, has been one of the most common causes of hemoptysis.This case report presents a patient with hemoptysis that may be a sequelae of chronic TB. However, further investigation reveals a concomitant non-tuberculous mycobacterial (NTM) infection and the co-existence of aspergilloma aggravating the condition. CASE PRESENTATION: She is a 62-year-old female who was admitted due to recurrent hemoptysis. She is a diabetic with no other known co-morbidities. Her chest radiograph showed ill-defined bilateral upper lung infiltrates. She has had treatment for TB previously but was uncompliant. Most recently, she has been in Category II of anti-tuberculosis therapy (ATT) returning after default. Multi-drug resistance tuberculosis (MDRTB) has been ruled-out. A chest CT scan was done and showed findings consistent with TB and bronchiectasis but a 2.3cm cavitary lesion, was seen in the right upper lobe with an apparent smaller satellite intra-cavitary nodule. We have worked on an impression of a concomitant aspergilloma.A flexible bronchoscopy was done showing blood clots on the right upper lobe were seen. Analysis of bronchial washings showed: Negative for malignant cells and Negative for fungal elements. Pending the results of the culture and considering a negative finding on fungal staining, she was re-started on ATT. A sputum specimen was likewise sent for culture. In 6 weeks time, both culture from bronchial washings and sputum revealed NTM which were slow growing and non-photochromogenic. It was negative for fungal growth. Therapy was then tailored for NTM. She has been asymptomatic while on treatment for NTM, but was readmitted on the 7th month of treatment with recurrent hemoptysis. A chest CT angiography was done to rule out a pulmonary vascular cause - and this was unremarkable for such. At this point we have come up with an impression of hemoptysis that may be probably due to three sources (1) TB broncheictasis, (2) NTM pulmonary infection, and (3) a possible Aspergilloma. A surgical consult was sought and she has consented to operation. An intraoperative bronchoscopy was done and was able to localize the bleeding in the right upper lobe. She underwent video-assisted thoracoscopy with right upper lobe lobectomy. The tissue diagnosis was an Aspergilloma, non-invasive. She has been symptom free up to present. DISCUSSION: The overlap of different disease conditions may aggravate a patient's presenting symptom. The association of TB and Aspergilloma has been widely reported. In areas where it is endemic, TB is still the most common condition predisposing subjects to aspergilloma formation. In a study in 2004, it was further stated that there was an association between the presence of Aspergillus antibodies and hemoptysis in patients with bronchiectasis. The most recent report of the co-existence between a pulmonary aspergillus and TB was presented in the latest bulletin of the WHO in 2011. In the Philippines, the estimated chronic pulmonary aspergillosis 5-year prevalence was 51% and this is after being treated with a PTB infection. In a report by Hafeez, four cases of pulmonary mycobacterial disease was complicated by the development of pulmonary Aspergillosis - making trratment difficult and prognosis worsened. In this case we have exhausted all efforts and means to diagnose the source of her hemoptysis. We were frustrated for such recurrence despite maximizing treatment. Nonetheless, she is doing better after surgery. However with underlying problems such as TB bronchiectasis and NTM infection, it will be uncertain if she remains well and it is probable that hemoptysis may recur. CONCLUSIONS: The co-exsistence of NTM and Aspergilloma may complicate hemoptysis in a patient with an underlying chronic pulmonary insult. All efforts must be exhausted and all diagnostic armaments be maximized in order to promptly address the needs of the patient.