PMC6355419_01
CT images of the development of pulmonary aspergillosis according to the lobes of the lungs. Chest high-resolution CT (HRCT) at the initial visit to our institute (a). Chest CT showed slightly expanded GGO accompanied by bronchiectasis (b). Chest CT on day 19 shows that GGO in both lungs had changed into nonspecific consolidation, and the area had spread (c).
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However, as PSL was tapered over the following two years, the symptoms of shortness of breath worsened and were accompanied by increased GGO on chest CT findings (Fig. 1a). Chest CT showed slightly expanded GGO with bronchiectasis (Fig. 1b). Chest CT showed that the GGO in both lungs had changed to consolidation, and the area had spread by day 19 (Fig. 1c). beta-D glucan, serum Aspergillus antibody, and Aspergillus antigen were 10,300 pg/mL, positive, and >5.0, respectively, and sputum culture revealed Aspergillus species.
Clinical course and laboratory data. Our patient underwent high-dose corticosteroid therapy from days 11 to 13. Mold was detected from the sputum several times, and the beta-D glucan levels became extremely elevated. The diagnosis was invasive pulmonary aspergillosis. Despite the use of antifungal agents, the patient ultimately died of respiratory failure on day 33. PSL: prednisolone, mPSL: methyl prednisolone, CsA: cyclosporine A, MCFG: micafungin sodium, L-AMB: liposomal-amphotericin B, CPFG: caspofungin, GCV: ganciclovir, ABPC/SBT: ampicillin sodium/sulbactam sodium, MEPM: meropenem, BT: body temperature, CRP: C-reactive protein, KL-6: Krebs von den Lungen-6, ND: no data
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The clinical course is shown in Fig. 2.
Pathological findings. Macroscopically, necrotic lesions were observed in the lungs [arrows, right (a), and left (b) sides]. EVG stain of basal part of left inferior lobe showed uniform interstitial inflammation and fibrosis, which is compatible with fibrotic nonspecific interstitial pneumonia (c: scale bar=1,000 mum). There were numerous Aspergillus hyphae with Y-shaped branching on parenchyma and alveoli (Grocott's methenamine silver stain; d: scale bar=100 mum). There were many lesions, such as bronchial pneumonia, in the inferior lobe of the right lung (e: Hematoxylin and Eosin staining, scale bar=1,000 mum). Aspergillus hyphae invaded the pulmonary vessels (f: EVG stain, scale bar=200 mum).
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A pathological autopsy revealed that both sides of the lungs were heavy and that necrotic lesions were observed macroscopically (Figs. 3a and 3b; arrows). Elastica Van Gieson (EVG) stain of the basal part of the left inferior lobe revealed homogeneous interstitial inflammation, fibrosis with thickening of interlobular septa, and no honeycomb lesions, findings that were compatible with f-NSIP (Fig. 3c). Many Aspergillus fungi were detected on the fibrotic parts and in airspaces (Fig. 3d). There were many lesions of bronchial pneumonia in the inferior lobe of the right lung (Fig. 3e). Some Aspergillus fungi had invaded the pulmonary arteries (Fig. 3f).