Abstract Introduction Chronic cavitary pulmonary aspergillosis (CCPA) develops in structurally abnormal lungs, most often following prior infections such as tuberculosis, atypical mycobacterial disease, or surgery. This case highlights the clinical evolution, diagnostic complexity, and management of CCPA in a patient with prior Mycobacterium avium complex (MAC) infection and left upper lobectomy. Case Presentation A 45-year-old male, long-term smoker with asthma, presented to the emergency department (ED) in 2019 following a motorcycle collision. Imaging revealed subdural and subarachnoid hemorrhages, and incidentally, a left upper lobe cavitary lesion. He reported a recent productive cough previously treated as pneumonia without imaging. Initial workup, including Beta-D-glucan, HIV, Hepatitis panel, Cryptococcal antigen, Histoplasma antigen, Blastomycosis antibody, and Aspergillus galactomannan antigen, was negative. AFB smear showed few acid-fast bacilli, but Gene Xpert was negative for Mycobacterium tuberculosis; culture confirmed Mycobacterium avium complex (MAC).He was managed with azithromycin, ethambutol, and rifabutin for one year. In 2022, worsening pulmonary symptoms and imaging progression necessitated a left upper lobectomy. Three years post-surgery, he re-presented with hemoptysis, 30-pound weight loss, and progressive dyspnea. Chest CT demonstrated worsening fibrotic and cavitary upper lobe-predominant disease with “tree-in-bud” opacities and nodular infiltrates (Figure 1). Bronchoscopy revealed friable mucosa and copious secretions. Bronchoalveolar lavage (BAL) cultures grew Aspergillus fumigatus, confirming the diagnosis of chronic cavitary pulmonary aspergillosis. Management and Outcomes The patient was treated with oral posaconazole for six months alongside continued MAC therapy. Insurance-related interruption led to transient symptom recurrence; therapy was resumed with clinical improvement marked by weight gain and reduced sputum production. Follow-up CT demonstrated persistent cavitary changes and multiple solid nodules, raising differential considerations of infection versus malignancy. The patient remains on long-term antifungal therapy and is under ongoing multidisciplinary surveillance. Discussion This case underscores the intersection of prior mycobacterial disease, surgical lung resection, and chronic fungal colonization as risk factors for CCPA. Imaging findings—including thick-walled upper lobe cavities, pleural thickening, and peri-cavitary infiltrates—supported the diagnosis per ESCMID/ERS/ECMM criteria. Serial follow-up remains essential to assess therapeutic response and exclude neoplastic progression. Conclusion CCPA should be considered in patients with progressive cavitary lung disease and prior MAC infection or lobectomy. Early identification, antifungal therapy adherence, and vigilant radiologic follow-up are crucial to improving outcomes. This abstract is funded by: None
Khalid et al. (Fri,) studied this question.