FUNGUS BALL, AN HEMOPTYSIS CAUSE IN A SLE PATIENT

PV291 / #290 Case Report Poster Topic: AS17 - Miscellaneous Introduction A fungus ball (mycetoma, aspergilloma) is a conglomeration of fungal hyphae intermingled with mucus and cellular debris, typically found within a pulmonary cavity. The most common cause is the colonization of preexisting fibrocavitary diseases, resulting from healed tuberculosis. Cavitary tuberculosis is relatively uncommon in individuals with systemic lupus erythematosus (SLE), and only few cases of fungus ball formation in tuberculosis cavities in these patients have been reported. Case Presentation With Investigation A 48-year-old man was diagnosed with SLE and antiphospholipid syndrome in 2007 based on the presence of positive antinuclear and anti-double-stranded DNA antibodies, immunoglobulin G and M anticardiolipin antibodies, oral ulcers, lymphopenia, nonerosive polyarthritis, class IV lupus nephritis, and a pulmonary embolism. His treatment included hydroxychloroquine, high-dose oral prednisolone (which was gradually tapered to a lower dose after achieving remission), and monthly intravenous cyclophosphamide up to a total of 7 grams, followed by azathioprine 100 mg/ day. In 2009, he developed disseminated tuberculosis (pulmonary and gastrointestinal compromise), for which he completed a 12-month antituberculosis treatment course. Fifteen years later, he was admitted due to recurring hemoptysis. Laboratory and imaging tests revealed native mitral valve endocarditis caused by Moraxella bovis. Chest imaging showed a mobile mass within a cavity in the left upper lobe (Figure). At that time, he was treated with warfarin, hydroxychloroquine 200 mg/day, and prednisolone 5 mg/day, with no signs of lupus activity (SLEDAI 0). The patient underwent surgery and histopathological studies confirmed the presence of a fungus ball due to Aspergillus flavus. Figure. A. Contrast-enhanced axial cranial tomography (CT) of chest: Black arrow points an oval shape mass at the dependent region of a cavity (Monod sign). B. Contrast-enhanced coronal cranial tomography (CT) of chest: Fungus ball with air crescent sign (white arrow) Literature Review The development of an aspergilloma usually occurs silently and is often asymptomatic; however, patients may experience chronic cough and hemoptysis. Radiologically, it typically appears as a mobile mass within a cavity to a gravity-dependent position frequently located in upper lobes (Monod sign). It may also show an “air crescent sign” (Figure) which indicates a separation between the fungus ball and the cavity wall, either partially or completely, and it is also observed in cases of pulmonary necrosis, pulmonary tuberculosis, hydatid cysts, Rasmussen aneurysm, and lung carcinoma. Due to its frequent surroundings of scarred and fibrotic lung tissue, the lesion can be challenging to detect on standard chest X-rays, making CT scans essential for confirmation. Treatment has not been standardized and some aspects remain controversial due to the unpredictable nature of the infection. Surgical resection is considered the gold standard for management, and perioperative or postoperative antifungal therapy with triazoles is recommended in patients with a high risk of surgical spillage. Discussion Impaired host immunity is considered a risk factor for postprimary tuberculosis. Patients with SLE often receive high doses of glucocorticoids and immunosuppressives, which can lead to reduced cellular immunity, thus increasing the risk of active tuberculosis. Aspergilloma formation can also occur in SLE patients within the same cavity. CT scans are a reliable diagnostic method for confirming this condition. Air crescent and Monod signs are distinctive features of aspergilloma, the latter helping to differentiate the fungal ball from other conditions and also helps in differentiating between causes of hemoptysis in SLE patients (eg, disease activity, infection, pulmonary embolism), thereby preventing unnecessary or invasive diagnostic measures and reducing the risk of potentially life-threatening complications.