A 72-year-old male enters with 2-year-old clinical picture of asthenia, adynamia, occasionally wet dry cough associated with functional class deterioration and moderate exertion dyspnea. He consults in another health center one year before the admission to our institution for the same symptoms where they perform fibro bronchoscopy and bronchoalveolar washing without insulation. He has an unclear history of untreated miliary tuberculosis. Since then he has presented multiple respiratory cases that resolved themselves. For 4 months with unexplained weight loss, increased symptoms with changes in the coloration of sputum and dyspnea of small efforts.
Family members indicate two weeks ago worsening of symptoms, functional class decrease, with dyspnea at rest and oxygen requirement by nasal cannula. He reports intermittent antibiotic administration, latest schema two months ago, does not remember which one.
At admission, the patient was emaciated, cachectic BMI 17, tachycardic 112 lpm, tachypneic 26 rpm, afebrile, with reduction of generalized vesicular murmur and rales in right lung base, the rest of the physical exploration was not remarkable.
Blood count of admission with mild leukocytosis 13000 cell/mm3 and neutrophilia 11000 cell/mm3, as well as elevated PCR (26 mg/dl). Chest X-ray showed decreased size of left lung, cleared left diaphragmatic angle cost and parenchyma presence of bilateral alveolar opacities, In addition, there is a rounded mass in the upper lobe of the left lung surrounded by radiolucent areas that suggest cavitations.
Computed tomography with chest contrast revealed "tree in bud" pattern in the upper right and middle lobe, peripheral consolidation patches and extensive frosted glass opacities in the lower right and left lobe. In the upper left lobe, there are lesions of a cystic appearance with a thick wall, the largest of 58 mm, with the presence of multiple masses with a density of soft tissues, the largest of 32 mm. Given the findings it is indicated to take thoracic tomography in prone.
The patient was taken to bronchial lavage with macroscopic evidence of purulent and greenish secretions of predominance in the bronchus for upper left lobe without endobronchial lesions, results are sent to pathology.
Bronchioalveolar lavage analyses demonstrate presence of +++ polymorphonuclears. Colorations of Ziehl neelsen, KOH, Giemsa and Gram were negative. Gene Xpert MTB-RIF was negative for Mycobacterium tuberculosis. The coloration of Gomory and Pas was positive for fungal structures, with evidence of hyphae with acute angles. Galactomannan in the bronchioalveolar lavage was negative, however, the culture was positive for Aspergillus fumigatus