PDF(Pubmed)
Abstract：
A 59-year-old non-smoking male, with a known case of COPD (chronic obstructive pulmonary disease), treated pulmonary tuberculosis with Category 1 antitubercular drugs (six-month regimen) and was admitted with repeated bouts of moderate haemoptysis (~60 mL/day) for three days. The patient had a history of self-limiting occasional mild haemoptysis (~20 mL) over three years. An HRCT chest revealed a left upper lobe fibro-cavitary lesion with an intracavitary mass (air crescent sign), adjacent pleural thickening and fibrosis. Bronchoalveolar lavage (BAL) was positive for galactomannan and negative for Mycobacterium tuberculosis GeneXpert®. With the above clinical factors, host factors, and microbiological factors, the case was diagnosed as \'probable\' invasive pulmonary aspergillosis and was treated with voriconazole. However, given relapsing haemoptysis despite adequate antifungal treatment, a left upper lobectomy was done. The resected left upper lobe specimen culture demonstrated Aspergillus fumigatus with histopathology confirming hyphae invading lung tissues confirming \'proven\' invasive aspergillosis. Resected tissue also showed florid lymphoid tissue hyperplasia with Immunohistochemistry confirming the presence of a peculiar malignancy; MALT lymphoma/MALToma in the resected lobe. The association of a rare malignancy such as MALToma with invasive pulmonary aspergilloma (IPA) has been identified and reported for the first time. This could be because of a chronic inflammatory reaction elicited by the Aspergillus antigen. Long-standing fibro-cavitary disease and aspergillosis are partners in crime, augmenting the damages inflicted by one another. In such a scenario, early surgical intervention may be warranted if haemoptysis is moderate to severe or relapsing, following conservative medical management. Surgical resection may lead to the identification of unexpected diseases as in our case.
摘要：
一名59岁的不吸烟男性,已知患有COPD（慢性阻塞性肺疾病）的病例，使用1类抗结核药物（六个月方案）治疗肺结核，并反复发作中度咯血（〜60mL/天），为期三天。该患者在三年内具有自限性偶发轻度咯血（约20mL）的病史。HRCT胸部显示左上叶纤维空洞性病变伴有腔内肿块（空气新月征），邻近胸膜增厚和纤维化。支气管肺泡灌洗(BAL)半乳甘露聚糖阳性,结核分枝杆菌GeneXpert®阴性。结合以上临床因素,宿主因素,和微生物因素，该病例被诊断为“可能”侵袭性肺曲霉病，并接受伏立康唑治疗。然而,尽管有足够的抗真菌治疗，但复发性咯血，做了左上叶切除术.切除的左上叶标本培养物显示烟曲霉，组织病理学证实有菌丝侵入肺组织，证实“已证实”侵袭性曲霉病。切除的组织还显示出花状淋巴组织增生，免疫组织化学证实存在特殊的恶性肿瘤；切除的肺叶中的MALT淋巴瘤/MALToma。已首次确定并报道了罕见的恶性肿瘤，例如MALToma与侵袭性肺曲霉菌瘤（IPA）的关联。这可能是由于曲霉抗原引起的慢性炎症反应。长期存在的纤维空洞病和曲霉病是犯罪的伙伴，增加彼此造成的损害。在这种情况下,如果咯血是中度至重度或复发性，可能需要早期手术干预，保守的医疗管理。手术切除可能会导致识别出意外疾病，就像我们的情况一样。
