Abstract Background Endobronchial aspergilloma (EBA) is a rare, noninvasive form of pulmonary aspergillosis characterized by fungal growth within the bronchial lumen without parenchymal invasion. It usually affects older or immunocompromised individuals with structural lung disease. Because clinical features mimic asthma or chronic bronchitis, diagnosis can be challenging. We present a unique case of EBA in a young, immunocompetent male initially misdiagnosed as refractory asthma. Case Presentation A 25-year-old previously healthy male presented with a two-year history of recurrent cough, chest congestion, and episodic dyspnea. Workup, including chest radiographs, respiratory viral panels, and complete blood count, was consistently negative. He was treated on multiple occasions with antibiotics and oral corticosteroids with transient improvement. A methacholine challenge demonstrated a 28% decline in FEV1, and the patient was managed as having moderate persistent asthma with inhaled corticosteroids/long-acting bronchodilators, with albuterol as needed. Despite adherence, symptoms persisted with progressive hoarseness and occasional hemoptysis, prompting further evaluation. High-resolution CT of the chest revealed a 6 mm left lower lobe nodule and patchy ground-glass opacities in the left upper lobe. Flexible bronchoscopy identified a white, plaque-like endobronchial lesion in the left upper lobe bronchus. Histopathology demonstrated reactive epithelial atypia with Grocott’s methenamine silver (GMS) staining positive for fungal hyphae morphologically consistent with Aspergillus species. There was no evidence of tissue invasion. Fungal culture confirmed Aspergillus fumigatus. Given persistent symptoms, a multidisciplinary team initiated oral voriconazole 200 mg twice daily for 6 weeks, resulting in complete clinical, bronchoscopic, and radiological resolution. Discussion This case highlights the diagnostic challenge of distinguishing refractory asthma from less common airway disorders. In young, immunocompetent individuals without underlying lung disease, EBA is extraordinarily rare, with only isolated cases reported in the literature. The clinical overlap with asthma emphasizes the need to consider fungal airway disease in cases unresponsive to optimal therapy, with bronchoscopy serving as a pivotal diagnostic tool for direct airway assessment. Although antifungal therapy is not routinely indicated for noninvasive EBA, individualized, symptom-driven management in collaboration with infectious disease specialists may result in excellent outcomes. This abstract is funded by: None
Hussain et al. (Fri,) studied this question.