Abstract A 57-year-old female with Stage I ER+ breast cancer (status post lumpectomy and radiation 8 months ago, currently on tamoxifen) presented with a six-month history of a progressive cough—initially dry, later productive of green sputum and worsened by deep inspiration—along with reduced exercise tolerance in the settings of increasing dyspnea over the past six months. Initial chest X-ray showed a new patchy right middle lobe (RML) opacity. She received several broad-spectrum antibiotics with partial symptomatic improvement, but both her symptoms and the opacity persisted. Chest CT revealed a dense RML opacity with endobronchial obstruction. Lung function tests were within normal range. Laboratory evaluation showed eosinophilia (11.9 ×10³/µL) and elevated IgE (759 IU/mL; reference 214). Aspergillus serologies were positive for A. fumigatus IgE (21.1; reference 0.7) and A. niger IgE (4.14; reference 0.7), while IgG to A. fumigatus, A. flavus, and A. niger were negative. Bronchoscopy with brush and biopsy demonstrated bronchial columnar cells, pulmonary macrophages, numerous eosinophils, Charcot-Leyden crystals, and fungal organisms morphologically consistent with Aspergillus species; no malignancy was identified. The patient was treated with 4 months of Isavuconazole, resulting in significant symptomatic improvement and resolution of RML mucous plugging on CT, with residual bronchiectasis and minimal distal mucous plugging. About two years after the initial episode, the patient developed recurrent symptoms with increased cough and green sputum containing more solid components, as well as difficulty taking deep breaths. She denied fever, chills, or hemoptysis. CT chest again showed right middle lobe airspace disease, likely due to mucus plugging versus an endobronchial lesion. Sputum cultures grew Aspergillus species, and RML brush cytology revealed scattered eosinophils with acute inflammatory changes. The patient was restarted on Isavuconazole. At 3-month follow-up, she reported feeling well with minimal cough, and CT chest demonstrated marked improvement with only small residual areas of mucus plugging. This case illustrates a rare presentation of endobronchial Aspergillus infection causing persistent right middle lobe opacity and post-obstructive pneumonitis in a patient without classic risk factors such as asthma, cystic fibrosis, or immunosuppression. Elevated eosinophil count, increased total serum IgE and Aspergillus-specific IgE, along with characteristic bronchoscopic findings on brush and biopsy, suggested allergic bronchopulmonary aspergillosis (ABPA) as the most likely diagnosis. Treatment with isavuconazole led to both symptomatic and radiographic improvement, underscoring the importance of considering fungal etiologies in persistent focal pulmonary opacities unresponsive to antibiotics. This abstract is funded by: None
Surta et al. (Fri,) studied this question.