Chronic pulmonary aspergillosis (CPA) encompasses a spectrum of pulmonary syndromes caused by progressive colonization by Aspergillus spp., especially in individuals with pre-existing structural lung disease. The chronic cavitary form (CCPA) is the most common presentation, frequently associated with pulmonary tuberculosis (TB), and is characterized by persistent inflammation, cavitations, and fungal ball formation. We report the case of a 28-year-old man living in the Complexo da Maré (Rio de Janeiro), with a history of TB treated in 2021, who presented with hemoptysis, weight loss, and dyspnea. He received a new empirical TB regimen with rifampicin, isoniazid, pyrazinamide, and ethambutol, without clinical improvement. In the final month of treatment, he was hospitalized with lower limb weakness and diagnosed with distal axonal neuropathy, possibly related to isoniazid. Re-evaluation revealed anti–Aspergillus fumigatus IgG serology >200 and CT showing extensive parenchymal destruction, cavitations, and a fungal ball. Voriconazole was initiated but later switched to liposomal amphotericin B due to hepatotoxicity. In February 2025, he underwent costectomy, cavernostomy, and pleurectomy, with histopathological confirmation of invasive fungal infection. Postoperatively, he developed a lung abscess with methicillin-resistant Staphylococcus aureus, treated with trimethoprim-sulfamethoxazole based on susceptibility testing. After clinical improvement, he was discharged in March 2025 with multidisciplinary outpatient follow-up and maintenance oral voriconazole, which was then well tolerated. This case highlights the diagnostic and therapeutic challenges of CCPA in individuals with prior TB, emphasizing the importance of clinical suspicion, early serological and radiologic confirmation, and surgical management in advanced cases. In primary care, empirical retreatment for TB should be carefully considered, and differential diagnoses such as fungal diseases must be investigated to avoid unnecessary therapies, adverse effects, and progression of untreated infections.
Barbalho et al. (Sun,) studied this question.