Haemoptysis in a female with diabetes mellitus: a unique presentation of chronic pulmonary aspergillosis, pulmonary tuberculosis, and
            Klebsiella peumoniae
            co‐infection

Abstract Background Diagnosis of chronic pulmonary aspergillosis (CPA) is based on a combination of clinical symptomatology, compatible chest imaging findings, evidence of Aspergillus infection and exclusion of alternative diagnosis, all occurring for more than 3 months. Recently, a rapid, highly sensitive and specific point-of-care lateral flow device (LFD) has been introduced for the detection of Aspergillus-specific immunoglobulin (Ig)G, especially in resource-limited settings where CPA is underdiagnosed and often misdiagnosed as smear-negative pulmonary tuberculosis (PTB). Therefore, in our setting, where tuberculosis (TB) is endemic, exclusion of PTB is an important first step to the diagnosis of CPA. We used the recently published CPA diagnostic criteria for resource-limited settings to identify patients with CPA in our center. Case presentation Three Ugandan women (45/human immunodeficiency virus (HIV) negative, 53/HIV infected and 18/HIV negative), with a longstanding history of cough, chest pain, weight loss and constitutional symptoms, were clinically and radiologically diagnosed with PTB and empirically treated with an anti-tuberculous regimen despite negative microbiological tests. Repeat sputum Mycobacteria GeneXpert assays were negative for all three patients. On further evaluation, all three patients met the CPA diagnostic criteria with demonstrable thick-walled cavities and fungal balls (aspergilomas) on chest imaging and positive Aspergillus-specific IgG/IgM antibody tests. After CPA diagnosis, anti-TB drugs were safely discontinued for all patients, and they were initiated on capsules of itraconazole 200 mg twice daily with good treatment outcomes. Conclusions The availability of simple clinical diagnostic criteria for CPA and a LFD have the potential to reduce misdiagnosis of CPA and in turn improve treatment outcomes in resource-limited settings.

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Chronic Pulmonary Aspergillosis Misdiagnosed as Smear-Negative Pulmonary Tuberculosis in a TB Clinic in Nigeria

Journal of Advances in Medicine and Medical Research ◽

10.9734/jammr/2018/41816 ◽

2018 ◽

Vol 26 (10) ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Titilola Gbaja-Biamila ◽

Felix Bongomin ◽

Nicholas Irurhe ◽

Augustina Nwosu ◽

Rita Oladele

Keyword(s):

Pulmonary Tuberculosis ◽

Pulmonary Aspergillosis ◽

Chronic Pulmonary Aspergillosis ◽

Smear Negative

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Mapping of Chronic Pulmonary Aspergillosis in Africa

Journal of Fungi ◽

10.3390/jof7100790 ◽

2021 ◽

Vol 7 (10) ◽

pp. 790

Author(s):

Ronald Olum ◽

Iriagbonse Iyabo Osaigbovo ◽

Joseph Baruch Baluku ◽

Jannik Stemler ◽

Richard Kwizera ◽

...

Keyword(s):

Risk Factor ◽

Pulmonary Tuberculosis ◽

Case Reports ◽

Case Series ◽

Important Risk Factor ◽

Chronic Obstructive ◽

Extensive Literature ◽

African Countries ◽

Pulmonary Aspergillosis ◽

Chronic Pulmonary Aspergillosis

Africa has a high burden of tuberculosis, which is the most important risk factor for chronic pulmonary aspergillosis (CPA). Our goal was to systematically evaluate the burden of CPA in Africa and map it by country. We conducted an extensive literature search for publications on CPA in Africa using the online databases. We reviewed a total of 41 studies published between 1976 and 2021, including a total of 1247 CPA cases from 14 African countries. Most of the cases came from Morocco (n = 764, 62.3%), followed by South Africa (n = 122, 9.9%) and Senegal (n = 99, 8.1%). Seventeen (41.5%) studies were retrospective, 12 (29.3%) were case reports, 5 case series (12.2%), 5 prospective cohorts, and 2 cross-sectional studies. The majority of the cases (67.1%, n = 645) were diagnosed in men, with a median age of 41 years (interquartile range: 36–45). Active/previously treated pulmonary tuberculosis (n = 764, 61.3%), human immunodeficiency virus infection (n = 29, 2.3%), diabetes mellitus (n = 19, 1.5%), and chronic obstructive pulmonary disease (n = 10, 0.8%) were the common co-morbidities. Haemoptysis was the most frequent presenting symptom, reported in up to 717 (57%) cases. Smoking (n = 69, 5.5%), recurrent lung infections (n = 41, 3%) and bronchorrhea (n = 33, 3%) were noted. This study confirms that CPA is common in Africa, with pulmonary tuberculosis being the most important risk factor.

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Chronic pulmonary aspergillosis commonly complicates treated pulmonary tuberculosis with residual cavitation

European Respiratory Journal ◽

10.1183/13993003.01184-2018 ◽

2019 ◽

Vol 53 (3) ◽

pp. 1801184 ◽

Cited By ~ 24

Author(s):

Iain D. Page ◽

Rosemary Byanyima ◽

Sharath Hosmane ◽

Nathan Onyachi ◽

Cyprian Opira ◽

...

Keyword(s):

Pulmonary Tuberculosis ◽

Chest Radiography ◽

Chronic Cough ◽

Reasonable Accuracy ◽

Pulmonary Aspergillosis ◽

Pulmonary Tb ◽

Pleural Thickening ◽

Radiological Features ◽

Chronic Pulmonary Aspergillosis ◽

Specific Igg

Chronic pulmonary aspergillosis (CPA) complicates treated pulmonary tuberculosis (TB), with high 5-year mortality. We measured CPA prevalence in this group.398 Ugandans with treated pulmonary TB underwent clinical assessment, chest radiography and Aspergillus-specific IgG measurement. 285 were resurveyed 2 years later, including computed tomography of the thorax in 73 with suspected CPA. CPA was diagnosed in patients without active TB who had raised Aspergillus-specific IgG, radiological features of CPA and chronic cough or haemoptysis.Author-defined CPA was present in 14 (4.9%, 95% CI 2.8–7.9%) resurvey patients. CPA was significantly more common in those with chest radiography cavitation (26% versus 0.8%; p<0.001), but possibly less frequent in HIV co-infected patients (3% versus 6.7%; p=0.177). The annual rate of new CPA development between surveys was 6.5% in those with chest radiography cavitation and 0.2% in those without (p<0.001). Absence of cavitation and pleural thickening on chest radiography had 100% negative predictive value for CPA. The combination of raised Aspergillus-specific IgG, chronic cough or haemoptysis and chest radiography cavitation had 85.7% sensitivity and 99.6% specificity for CPA diagnosis.CPA commonly complicates treated pulmonary TB with residual chest radiography cavitation. Chest radiography alone can exclude CPA. Addition of serology can diagnose CPA with reasonable accuracy.

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Global burden of chronic pulmonary aspergillosis as a sequel to pulmonary tuberculosis

Bulletin of the World Health Organization ◽

10.2471/blt.11.089441 ◽

2011 ◽

Vol 89 (12) ◽

pp. 864-872 ◽

Cited By ~ 166

Author(s):

David Denning ◽

Alex Pleuvry ◽

Donald Cole

Keyword(s):

Pulmonary Tuberculosis ◽

Global Burden ◽

Pulmonary Aspergillosis ◽

Chronic Pulmonary Aspergillosis

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A prospective longitudinal study of chronic pulmonary aspergillosis in pulmonary tuberculosis in Indonesia (APICAL)

10.1101/2021.04.25.21256062 ◽

2021 ◽

Author(s):

Findra Setianingrum ◽

Anna Rozaliyani ◽

Robiatul Adawiyah ◽

Ridhawati Syam ◽

Mulyati Tugiran ◽

...

Keyword(s):

Pulmonary Tuberculosis ◽

De Novo ◽

Significant Risk ◽

Fungal Culture ◽

Bottom Line ◽

Pulmonary Aspergillosis ◽

Prospective Longitudinal Study ◽

Chronic Pulmonary Aspergillosis ◽

Specific Igg ◽

Prospective Longitudinal

AbstractObjectivesChronic pulmonary aspergillosis (CPA) can complicate recovery from pulmonary tuberculosis (TB). CPA may also be misdiagnosed as bacteriologically-negative TB. This study aimed to determine the incidence of CPA in patients treated for TB in Indonesia; a country with a high incidence of TB.MethodsIn this prospective, longitudinal cohort study in patients treated for pulmonary TB, clinical, radiological and laboratory findings were analysed. Sputum was collected for fungal culture and TB PCR. Patients were assessed at baseline (0-8 weeks) and at the end (5-6 months) of TB therapy. CPA diagnosis was based on symptoms (>3 months), characteristic radiological features and positive Aspergillus serology, and categorized as proven, probable and possible.ResultsOf the 216 patients recruited, 128 (59%) were followed up until end of TB therapy. At baseline, 91 (42%) had microbiological evidence for TB. Aspergillus-specific IgG was positive in 64 (30%) patients and went from negative to positive in 16 (13%) patients during TB therapy. The incidence of proven and probable CPA at baseline was 6% (n=12) and 2% (n=5) and end of TB therapy 8% (n=10) and 5% (n=7), respectively. Six patients (2 with confirmed TB) developed an aspergilloma. Diabetes mellitus was a significant risk factor for CPA (p=0.040). Persistent cough (n=5, 50%; p=0.005) and fatigue (n=6, 60%; p=0.001) were the most common symptoms in CPA.ConclusionCPA should be considered a relatively frequent differential diagnosis in patients with possible or proven TB in Indonesia. Lack of awareness and limited access to Aspergillus-specific IgG tests and CT imaging are obstacles in establishing a CPA diagnosis.Key messagesWhat is the key question?Do what extent is chronic pulmonary aspergillosis (CPA) both a) mistaken for TB and b) co-exists with TB during the course of 6 months therapyWhat is the bottom line?Features consistent with CPA were present in 6% of patients when starting TB therapy and 8% at the end of therapy, with some resolving and some developing CPA de novo during TB therapy. At the end of B therapy symptoms, cavitations with Aspergillus-specific IgG detectable were the key features of CPA.Why read on?Co-existence of TB and CPA is present in a substantial minority of patients starting and ending TB therapy, and needs addressing in terms of diagnosis, dual therapy and follow up.

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