|LETTER TO EDITOR
|Year : 2011 | Volume
| Issue : 1 | Page : 137-138
Aspergillus - The great masquerader
U Devaraj1, R Priya1, J Savio2, GA Dsouza1
1 Division of Chest Medicine, St.John's Medical College and Hospital, Bangalore - 560 034, India
2 Department of Microbiology, St.John's Medical College and Hospital, Bangalore - 560 034, India
|Date of Web Publication||10-Feb-2011|
Division of Chest Medicine, St.John's Medical College and Hospital, Bangalore - 560 034
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Devaraj U, Priya R, Savio J, Dsouza G A. Aspergillus - The great masquerader. Indian J Cancer 2011;48:137-8
The Aspergillus species are ubiquitous environmental molds. Invasive pulmonary aspergillosis (IPA) is the most common manifestation of aspergillus infection in immunosuppressed patients. Prolonged neutropenia, use of high-dose steroids, poorly controlled diabetic status, HIV infection, and burns are risk factors for IPA. We report a case of invasive aspergillosis in an immunocompetent host, which was masking the underlying malignancy.
A 76-year-old male presented with complaints of cough of six months duration. He was on treatment with multiple courses of antibiotics for the same complaint, but his symptoms did not resolve. The patient's history was significant for 300 pack-years of smoking and diabetes with well-controlled sugar. The physical examination revealed signs of a mass in the left lower lobe. His hemogram and biochemical parameters were within normal limits. His chest radiographs revealed a persistent non-homogenous opacity on the left lower zone, which did not silhouette the cardiac shadow [Figure 1]. His chest CT scan showed a mass in the left lower lobe, posterior segment, with a few subcarinal lymph nodes [Figure 2]. A provisional diagnosis of carcinoma lung was made.
A bronchoscopic biopsy revealed extensive necrosis and fungal filaments morphologically similar to aspergillus, which was confirmed by fungal culture. A percutaneous aspirate and biopsy of the lesion showed no malignant cells and a few structures suspicious of fungal elements. A diagnosis of IPA was made and he was started on amphotericin B. There was no improvement in the lung shadow, although there was a marginal improvement, clinically, at the end of two weeks. He was offered curative surgery - lobectomy of the involved lobe. During thoracotomy an inoperable large mass was seen in the left lower lobe crossing the interlobar fissure and growing into the left upper lobe, with multiple mediastinal lymph nodes. The biopsy of the mass revealed poorly differentiated squamous cell carcinoma. The amphotericin B course was continued and the patient was offered treatment for cancer.
|Figure 1a: Chest Roentgenogram prior to therapy. Left lower lobe non-homogenous opacity|
b: The chest roentgenogram showed no improvement after two weeks of treatment
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|Figure 2: CT thorax showed a dense opacity in the lateral segment of the left lower lobe|
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Our patient was diagnosed with IPA, based on the histopathological evidence of lung tissue invasion associated with non-resolving consolidation.  IPA is reported in a setting of severe immunocompromised status or in poorly controlled diabetics.  Our patient had neither of the conditions. The presentation of IPA often mimics acute bacterial pneumonia.  Our patient's duration of illness lasted for more than six months.
There are a few case reports of necrosis of the tumor with fungal elements.  Two cases of aspergillus associated with non-cavitary lung cancer have been reported.  Our patient had no evidence of necrosis on CT thorax. Proof of invasive aspergillus required the demonstration of septate hyphae, with acute angle branching in the tissues. This was the reason the patient was subjected to a percutaneous biopsy in spite of having a positive diagnosis from bronchoscopic biopsy. In a case report, Yoshimoti A et al, established the diagnosis of carcinoma after 12 bronchoscopies. 
The underlying malignancy was obscured in spite of repeated invasive diagnostic procedures. Localized pulmonary aspergillosis can occur in association with primary lung carcinoma, which can lead to a delay in the diagnosis of carcinoma.
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[Figure 1], [Figure 2]