PMC7723802_01
Chest radiographic images of the patient. Chest X-ray images 4 months before admission (A), 4 weeks before admission (B), on admission (C), and admission on day 14 (D). Arrows indicate newly emerging club-shaped masses in both lungs. The image on day 14 was performed by bedside X-ray in the anteroposterior (AP) sitting position.
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His chest X-ray image showed newly emerging club-shaped masses in both lung fields (Fig. 1). Although his chest X-ray showed persistent club-shaped masses in both lung fields (Fig. 1C), no abnormal respiratory sounds with improved eosinophilia (Fig. 3) suggested the partial effect of prednisolone treatment for His chest X-ray showed newly emerging lung infiltration in the right lower lung field compared to that on admission (Fig. 1D).
Chest CT images of the patient. (A) Mucus plugging and tree-in-bud opacities were apparent before prednisolone treatment and (B) at the time of mepolizumab treatment. (C) Mucus plugging was resolved 43 days after mepolizumab treatment.
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Chest computed tomography (CT) showed central bronchiectasis, mucoid impaction, and tree-in-bud opacities (Fig. 2A). The IgE level tended to decrease at 5220 IU/mL, and mucus plugging was resolved 43 days after mepolizumab treatment (Fig. 2C).
Clinical course of the case. The patient was treated with 30 mg/day of prednisolone (PSL) for ABPM starting 12 days before admission. He developed bilateral septic arthritis of the knees caused by Methicillin-resistant Staphylococcus aureus (MRSA) during prednisolone treatment. He underwent bilateral arthroscopic washout with a 2-week course of intra-articular arbekacin (ABK), concomitantly treated with a 6-week course of intravenous teicoplanin (TEIC) and oral rifampicin (RFP). He suffered exacerbation of ABPM during treatment of the septic arthritis and was treated with mepolizumab on admission day 15. Garenoxacin (GRNX) followed by tazobactam/piperacillin (TAZ/PIPC) was transiently administered for the treatment of bronchopneumonia by Pseudomonas aeruginosa from day 16 to day 27. He was discharged on day 43.
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He was clinically diagnosed with allergic bronchopulmonary aspergillosis/mycosis (ABPA/ABPM) (Table 1) and treatment was initiated with 30 mg/day of prednisolone 12 days before admission (Fig. 3). Eosinophil cell count rose linearly, reaching 2966/muL on day 14 (Fig. 3). Garenoxacin followed by tazobactam/piperacillin was transiently administered for treatment of Pseudomonas aeruginosa bronchopneumonia from day 15 to day 27 (Fig. 3).
Bronchoscopic findings showing a mucoid plug in the left lingular bronchus.
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Mucus plugs were later confirmed by bronchoscopy after admission (Fig. 4), although fungal hyphae were not detected, presumably because of the effect of treatment.
Clinical features of septic arthritis of the knee. (A) An MRI of the right knee revealed a small amount of joint fluid retention in the knee and a hyperintense signal in the soft tissues of the medial aspect of the lower leg, based on T2 weighted-image sequencing. (B) Gram stain of knee synovial fluid showed Gram-positive cocci being phagocytosed by neutrophils.
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T2 weighted-image sequencing (Fig. 5A). There was also synovitis around the suprapatellar capsule. A needle aspiration from the right knee revealed thick, cloudy pus with Gram-positive cocci being phagocytosed by neutrophils (Fig. 5B). which proved to be MRSA.