Abstract Introduction Chronic pulmonary aspergillosis (CPA) is a rare infection by Aspergillus fumigatus that develops in structurally damaged lungs such as those with COPD or emphysema. Persistent inflammation accelerates parenchymal destruction, worsening fibrosis and predisposing to further opportunistic infections. We present a case of CPFE complicated by chronic cavitary pulmonary aspergillosis and Mycobacterium avium complex infection- a hemorrhagic cascade of cavities. Case Then aged 60, this patient with a history of heavy smoking, DVT/PE s/p IVC filter, opioid use presented in 2013 with hemoptysis. Imaging showed an 8 cm RUL cavity with thin walls superimposed on previously known bilateral upper-lobe bullous emphysema, adjacent bronchiectasis and interstitial fibrotic changes consistent with Combined Pulmonary Fibrosis and Emphysema (CPFE). An extensive evaluation including multiple BALs over 2013-2014 was negative for AFBs but yielded fungal organisms Aspergillus fumigatus and Candida albicans. A diagnosis of chronic pulmonary aspergillosis (CPA) was made, and voriconazole therapy was initiated.The next decade was characterized by intermittent anti-fungal therapy and scattered follow-up complicated by homelessness and ongoing substance use. Management of COPD symptoms included inhaled corticosteroids and courses of oral steroids for exacerbations. In June 2025, the patient presented with brisk hemoptysis prompting an emergent bronchoscopy to localize the bleed and treated with an LUL bronchial artery embolization. Repeat imaging demonstrated progression of bilateral upper-lobe bullous disease, fibrosis and bilateral fungal balls, the largest in the previous RUL cavity and another in the LUL, explaining the source of the bleeding. BAL cultures again grew Aspergillus flavus and now superimposed Mycobacterium avium complex (MAC). The patient was re-intiated on antifungal therapy with isavuconazole; management focused on aspergillosis in the acute period as MAC was deemed a colonizer. Recurrent hemoptysis led to 2 further hospitalizations which were managed conservatively. Multidisciplinary follow-up continues for chronic cavitary pulmonary aspergillosis (CCPA) in the context of CPFE, with the primary goal of preventing further life-threatening hemorrhage from invasive aspergillomas. Discussion Longstanding CPFE creates a substrate for opportunistic colonization. Interruptions in antifungal therapy and corticosteroid use for suspected COPD exacerbations likely promoted fungal growth, leading to invasive aspergillomas and a high risk of recurrent bleeding. Coexistence of CCPA and MAC within the same cavities is rare and challenging, requiring multidisciplinary management. References: Yamakawa H, et al. Patient Background and Prognosis of Chronic Pulmonary Aspergillosis in Fibrosing Interstitial Lung Disease. Respir Investig. 2022;60(5):586-593. Fayos B, et al. Non-Tuberculous Mycobacteria and Aspergillus Lung Co-infection: A Systematic Review. J Fungi (Basel). 2022;8(10):1080. This abstract is funded by: none
Pandharpurkar et al. (Fri,) studied this question.