Pulmonary Mass: Invasive Pulmonary Aspergilloma and Pulmonary Tuberculosis in Patient With Pulmonary Amyloidosis in Light Chain Kappa Type Multiple Myeloma

Abstract

INTRODUCTION: Tuberculosis and aspergillosis are opportunistic infections. Its significance has dramatically increased with growing number of patients due to widespread use of chemotherapy and immunosuppressive agents.1These diseases as co-infection with Pulmonary Amyloidosis are rarely encountered. CASE PRESENTATION: A case of a 51 y.o. female, admitted due to pneumonia.She underwent hemodialysis due to azotemia. Referred to hematologist because of hypercalcemia, bycytopenia, azotemia and compression of L4. Myeloma work up showed Serum protein electrophoresis, a small irregular peak at the mid-gamma region highly suspicious of gammopathy. Immunofixation electrophoresis confirmed clonality with monoclonal free kappa light chain. Bone marrow biopsy showed hypercellular marrow with 40% plasma cells. Skeletal survey showed lytic lesions. Chemotherapy was started. Chest Xray showed diffuse right lower zone air-space shadowing and pulmonary mass left lower lobe. CT scan revealed pulmonary mass on the left lower lobe probably metastatic versus infectious process. Echocardiogram showed Pulmonary hypertension. During her hospital course, there's massive bleeding per tracheostomy tube. She was in and out of ventilator despite broad spectrum antibiotics. Weaning process failed several times. Open lung biopsy showed an acute, septate branching hyphae invading the blood vessels with positive culture for aspergillosis.There's granuloma with Langhan's type giant cells consistent with pulmonary TB. Histochemistry performed using congo-red stain revealed red orange deposit within the interstitium and surrounding vessels, polarizing microscopy confirmed the apple-green birefringence consistent with pulmonary amyloidosis. Persistent arrhythmia with unstable vital signs, patient expired DISCUSSION: Pulmonary mass can either be malignant or infectious. In this case result was tuberculosis with aspergilloma. Aspergillus, invades lung parenchyma in a pre-existing cavity of the mycobacterium tuberculosis. WHO reported in 2011 that 25% of patients diagnosed with pulmonary TB had detectable Aspergillus in blood, and both precipitins and radiological features are detectable in 14% at 12 months and 22% at 3-4 years. But there is no incidence report on the concomitant amyloidosis infection in patients with Pulmonary TB and/or Aspergilloma. Amyloidosis is life-threatening.Renal amyloidosis was linked to pulmonary tuberculosis in 9-11% of cases, but no local or international literature can be found regarding pulmonary amyloidosis complicating pulmonary tuberculosis and/or aspergilloma.No recent data is also available. The amyloid in pulmonary amyloidosis can either be AL or AA and is commonly associated with the systemic type.Patients with amyloidosis are asymptomatic, thus can be missed out if not biopsied. Patient presented with non-resolving pneumonia, cannot sustain spontaneous respiration with continued complications despite broad spectrum antibiotics. Infectious and malignant causes were already addressed.Upon open biopsy pulmonary amyloidosis was diagnosed.Management of this type of amyloidosis is dependent on severity. In this case the symptomatic patient requires treatment but unfortunately due its relative rarity and the lack of trials, there is not definite management at present CONCLUSIONS: Pulmonary amyloidosis in multiple myeloma complicating Pulmonary Tuberculosis and/or Aspergilloma is a novel finding. This could have been influential to the demise of the patient. Thus, knowing such case could contribute to the differential diagnosis in a patient with worsening and non-resolving condition.