Case Report
Aspergilloma and Precipitin Test: Report of Two Cases
Pannakorn Imwidthaya M.D. *
Arporn Boonyakurkul M.D. **
Somboon Srimuang M.Sc. ***
Abstract Two cases of pulmonary aspergilloma were reported. The first case was Chinese who has
smoked 10-20 cigarettes per day since he was 16 years old and was diagnosed pulmonary
tuberculosis since he was 62 years old. The second case was 82 years Thai female farmer and was
diagnosed pulmonary tuberculosis when she was 72 years old. Both were treated with full course
of anti-tuberculous drugs. Their complaints were dyspnea, cough with occasional bloody
sputum. Sputum cultures forM. tuberculosis were negative. Chest X-rays revealed fungus balls
inside the dry cavities. Antibodies againstA.fumigatus were detected in precipitin lines using gel
diffusion method which yield the highest titer of 1:8. A. fumigatus was also isolated from the
first case.
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Aspergilloma is a solid "ball" of fungal mycelia Aspergillus species are widely distributed in na
produced in situ. 1 It is usually formed over several ture, and hence available as infectious agents. Pulmo
months or years within a preexisting cavity. It may nary tuberculosis is the fourth most important cause of
follow tuberculosis or other types of cavitating lung death in the Thai population, and the leading cause
disease such as bronchiectasis. Aspergilloma may also among infectious diseases. 2 Aspergillosis had been
form in cavities caused by other fungal infections such sporadically reported,3A usually during clinical diagno
as coccidioidomycosis. sis based on surgery or autopsy. In Thailand, the greatest
*Department of Microbiology, Siriraj Hospital, Bangkok 10700 number of cases of surgical aspergillosis, including
**Anti-tuberculosis Association Hospital, Bangkok 10400 aspergilloma, have been reported from the Central Chest
***Division ofInfectious Disease and Host Defense Unit, Research Hospital, Nontaburi, where 55 patients, aged 16-69
Center, Ramathibodi Hospital, Bangkok 10400 years have been found infected. s We would like to
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report two cases of aspergilloma from the Anti-Tuber mycological study for 3 consecutive days and revealed
culosis Association Hospital, diagnosed by chest X-ray growth of Aspergillusjumigatus. The serum was tested
and precipitating antibodies against Aspergillus species. for Aspergillus antibodies, and revealed precipitin to
Case No.1. A Chinese man 72 years old had a Aspergillus jumigatus, A. flavus and A. niger at titers of
history of pulmonary tuberculosis since he was 62 years 1:8,1:1 and 1:1, respectively.
old. He attended the Anti-Tuberculosis Association The patient was a Chinese actor. He had smoked
Hospital in 1984, when chronic pulmonary tuberculosis 10-20 cigarettes per day between the ages of 17 to 62.
was diagnosed and an anti-tuberculous drug was pre Case No.2. A Thai woman 82 years old who had
scribed. His sputum for acid-fast bacilli was negative a history of pulmonary tuberculosis since age 72. On 7
on several occasions. Since 1985, the patient had August 1990 she was admitted to the Anti-Tuberculosis
developed cough, dyspnea, dizziness and recurrent he Association Hospital because of dyspnea, malaise and
moptysis, and has been admitted periodically to the hos recurrent hemoptysis. Chronic obstructive pulmonary
pital. disease with cachexia was diagnosed.
The patient looked old for his age on last admission On admission the patient looked cachetic. Auscul
(12 March 1990). Auscultation revealed crepitation and tation revealed crepitation and rhonchi left upper lung;
rhonchi at right upper lung; the others were within the other was within normal limits.
normal limits. Laboratory examination revealed hemoglobin 11
Laboratory examination revealed hemoglobin 15 gm per cent, hematocrit 35 per cent, white blood cells
gm per cent, hematocrit 50 per cent, white blood cells 13, 1OO/cu.mm., with 80 per cent neutrophils and 20 per
11, 600/cu.mm., with 85 per cent neutrophils and 15 per cent lymphocytes.
cent lymphocytes. Results of urine, faeces and blood PA film ofthe chest revealed fibro-nodular infiltra
chemistry were not remarkable. tion in left lung with some loss of the lung volume, most
PA film of the chest showed fibronudular lesions likely representing chronic pulmonary tuberculosis. Two
involved both upper lungs associated with some cystic soft tissue masses were noted over the left upper lobe,
like appearance and loss ofthe right lung volume. There measuring about 4.5x5.5 cm and 4x3.5 cm in diameter
was a crescent of air around a soft mass of tissue in the with an appearance of cresent sign, highly diagnostic of
right upper lobe representing an intra-cavitary fungus the fungal balls. Minimal fibrotic with emphysematous
ball of aspergilloma (Fig. 1). Sputum was sent for change was also seen in the right upper lobe scar. The
visualized bony thorax was intact. Sputum was sent for
mycological study for 3 consecutive days, but revealed
no growth. The serum was tested for Aspergillus anti
bodies and revealed precipitin to A.fumigatus, A.flavus
and A. niger at titers of 1:8, 1: 1 and 1: 1, respectively.
The patient was a Thai farmer without any history
of smoking.
DISCUSSION
Aspergillomas are most commonly associated
with either active or healed tuberculosis. In a survey of
544 patients with post tuberculous cavities in 55 chest
clinics in Great Britain, 17 per cent of the patients had
definite aspergilloma and 3 per cent had probable
aspergilloma. 6 We studied 105 patients who attended
Anti-Tuberculosis Association Hospital and found two
cases, one with confirmed and the other with probable
aspergilloma. The important symptoms were recurrent
hemoptysis, cough and malaise. Physical examination
revealed diminished breath sound in the area corre
Fig. 1 PA film of case No.1 showing the crescent of air sponding to the cavity. Blood examination usually was
around the soft tissue mass in the right upper not remarkable. We were able to culture the fungus from
lobe, representing the intra-cavitary fungus ball the sputum in only one case but Aspergillus antibodies
of aspergilloma. showed high titers in both when tested withA.fumigatus,
Vol. 7 No. 4 Oct. -Dec. 1990 J Infect Dis Antimicrob Agents 203
indicating that aspergilloma was caused by A. fumiga ACKNOWLEDGEMENT
tus, A.flavus or A. niger respectively.? We were able to The authors would like to thank Dr. Warren Brock- .
culture the fungus from the sputum in only one case but elman for reviewing the manuscript, Dr. Paul S Stan
Glimp and Bayer8 found an overall incidence of he dard, Center for Disease Control, Atlanta, Georgia,
moptysis in cases of aspergilloma of 74 per cent, and U.S.A. for supplying reference Aspergillus antigens and
sputum cultures were positive in only 50 per cent of antibodies.
cases, whereas Aspergillus precipitin was found in 92
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