Aspergillus is a fungus which is commonly found in the soil, food, plant debris, and indoor environment. The spores are easily aerosolized and inhaled. In the respiratory mucosa, the spores may germinate into hyphae, which in turn can invade the mucosa leading to pulmonary aspergillosis. [1] It manifests clinically as spectrum of lung diseases and includes invasive pulmonary aspergillosis, allergic bronchopulmonary aspergillosis, chronic necrotizing aspergillosis, aspergilloma and chronic cavitary pulmonary aspergillosis. Recently the incidence of these fungal infections increased incidence with significant increase in morbidity and mortality. [2] 

A 68 years old male farmer had no known previous co-morbidities, presented with fever for 2 months which was intermittent documented up to 101⁰ F associated with chills and rigor, cough with expectoration. He had 3-4 episodes per week of heamoptysis which was mild consisted of 5-10 ml of blood. After one month of illness, he complained of sharp pricking pain inright lower part of chest which got aggravated on deep breaths and cough. The patient also had insidious onset breathlessness which over a period of 10 days gradually progressed from MMRC III to MMRC IV. On clinical examination there were coarse crepitations in right lung fields with occasional wheeze in left infra-axillary area. Laboratory evaluation revealed leukocytosis, deranged blood sugar and high HbA1c. Tuberculosis work up was negative. On Chest X-ray multiple cavitary lesion were found on right side (Figure 1). CT bronchial angiography revealed mild hypertrophied, tortuous right bronchial artery, multiple cavitary lesion in right lung, aspergilloma in right upper lobe and right sided hydropneumothorax. Right sided intercoastal chest tube drainage was done. Pleural fluid examination had marked leukocytosis with low sugar and septate hyphae on smear. Final diagnosis of pulmonary aspergillosis with pyopneumothorax was made. Treatment with intravenous antibiotics and amphotericin B was given.

Figure 1-Chest X-Ray of Patient with Multiple Cavitary Lesions on Right Side.

Aspergillosis typically develops in immunocompromised patient but our case was an exception who was normal male with no co-morbidities. The diagnosis is difficult because of overlapping presentation of pulmonary tuberculosis, malignancy, mucormycosis and histoplasmosis. Lower respiratory tract symptoms such as cough with or without sputum production, respiratory distress, wheezing, and fever are common. Aspergillus has a predilection for invading vasculature, especially in the neutropenic patients, leading to thrombosis, tissue infarction, and necrosis. In such cases pleuritic chest pain and hemoptysis may be present. [3] Heamoptysis is one of the most devastating complications of pulmonary aspergillosis and is reported in 64%–83% of cases with aspergilloma. [4] Surgery and antifungals are the main stay of treatment. Surgery should be reserved for patients with unilateral localized disease, failure of medical treatment and to treat complications such as haemoptysis. [5] This case illustrates that the diagnosis of aspergillosis must be suspected early on and prompt treatment initiated to prevent further complications.

The authors declare that they have no conflict of interest.

No funding sources

The study was approved by the Institutional Ethics Committee of Regional Hospital, Kullu.

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4. Jewkes, Jonathan, et al. "Pulmonary aspergilloma: analysis of prognosis in relation to haemoptysis and survey of treatment." Thorax 38.8 (1983): 572. https://doi.org/10.1136/thx.38.8.572.

5. Betancourt, Blas Y., et al. "Pulmonary aspergillosis presenting with recurrent haemoptysis." Case Reports 2015 (2015): bcr2015211249. https://doi.org/10.1136/bcr-2015-211249