Pulmonary aspergillosis diagnosed during surgical treatment for spontaneous pneumothorax: a case report

Introduction

Pulmonary aspergillosis is a respiratory disease caused by Aspergillus species. Patients with underlying structural lung diseases such as cavities, cysts, emphysematous changes, or bronchiectasis could become infected with inhaled Aspergillus organisms and form lesions, because of failure of the local immune system. Chronic pulmonary aspergillosis (CPA) often presents with no symptoms, but respiratory symptoms such as bloody sputum and cough may trigger detection of the disease (1). Even asymptomatic patients may be diagnosed as having CPA after closer examination of abnormalities on chest computed tomography (CT).

Herein, we report a rare case in which CPA was diagnosed during surgical treatment for spontaneous pneumothorax. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-226/rc).

Case presentation

An 86-year-old man presented to his physician with the chief complaint of cough. Chest radiography revealed a right pneumothorax, for which thoracic drainage was initiated (Figure 1A). However, the air leak persisted and the subcutaneous emphysema gradually worsened (Figure 1B). On day 7 of illness, the patient was transferred to our hospital for surgical management. His medical history included right-sided pulmonary tuberculosis treated medically 22 years earlier, and autoimmune hepatitis, for which treatment with oral prednisolone 10–30 mg daily had been initiated 3 months earlier. At transfer, two thoracic drains were in place with continuous suction at −20 cmH₂O. Extensive subcutaneous emphysema was present, involving the neck, trunk, and bilateral upper arms. Chest CT performed the day before the transfer revealed numerous cysts and cavities in the right lung, although the precise site of air leak could not be identified (Figure 1C). The right lung apex was adherent to the chest wall, with a small nodule seen within a lung cavity (Figure 1D). Interstitial changes were also evident throughout both lungs.

Figure 1 Preoperative radiologic images. (A) Chest radiograph immediately after placement of a chest tube to treat the right pneumothorax. (B) Chest radiograph on day 7 (the day of transfer to our hospital). The right lung was poorly expanded and the subcutaneous emphysema had worsened. (C,D) Chest computed tomography on day 6 (the day before transfer). The right lung is adherent at the apex, and a small nodule can be seen in the adherent lung cavity in the coronal section (D, arrow).

The patient continued to have a large persistent air leak with a collapsed right lung, and the subcutaneous emphysema spread further to the neck. Given these findings, we planned thoracoscopic surgery. Thoracoscopy revealed multiple adhesions between the lung and chest wall. The thoracic cavity contained exudative pleural effusion and fibrinous material consistent with acute empyema in the exudative to fibrinopurulent stage. A grayish, necrotic-appearing mass measuring 10 mm in diameter was found adhering to the outer surface of the right upper lobe, obstructing a 5-mm pulmonary fistula (Figure 2). This material was carefully removed en bloc to avoid spillage into the thoracic cavity. Intrapleural fibrin clots were also debrided as thoroughly as possible, and the thoracic cavity was irrigated extensively with 2,500 mL of saline before closure of the pulmonary fistula. Because the adherent material appeared to be fungal in nature, a wide wedge resection including the fistula site was performed, rather than direct suture closure. The lung surrounding the fistula was densely adherent to the chest wall and was dissected extrapleurally to avoid parenchymal injury. The fistula was located on the wall of a lung cavity, and the adjacent lung parenchyma was sclerotic. Both the cyst and the sclerotic lung tissue were resected en bloc using a stapling device. The operative time was 103 minutes, and the estimated blood loss was 5 g.

Figure 2 Intrathoracic findings during surgery. (A) A 10-mm grayish necrotic-like material was attached to the upper lobe of the right lung, blocking a 5-mm pulmonary fistula. (B) The necrotic-like material was removed externally, and the pulmonary fistula was exposed.

Since intraoperative pleural fluid cultures were negative for fungi, we removed the thoracic drain on postoperative day 1. However, culture of the necrotic fistula-associated material collected intraoperatively grew fungal elements, prompting initiation of treatment with voriconazole on postoperative day 2. On postoperative day 5, the isolate was identified as Aspergillus fumigatus, and the serum aspergillus antigen test was positive. The patient’s postoperative course was uneventful, and he was discharged on postoperative day 7. Oral voriconazole was continued at 400 mg daily for 3 months postoperatively and then discontinued after confirming resolution of the inflammation without recurrence. No evidence of recurrence of the pulmonary aspergillosis was observed at the 2-year follow-up.

Histopathological examination revealed that the sclerotic lesion in the resected lung was due to atelectasis, with nodular scarring and dry necrosis within the lesion. The pulmonary sclerosis was considered as a sequela of prior pulmonary tuberculosis. Fungal growth was observed in the lung cavity wall of the resected specimen (Figure 3).

Figure 3 Histopathologic findings. (A) Cross-section of a partially resected pulmonary cyst (macrophotograph). The cyst was accompanied by a nodular scar which was necrotic (arrow). (B) Photomicrograph of hematoxylin and eosin stain. (C) Grocott’s stain photograph showing fungal growths on the cavity wall. (D) Periodic acid-Schiff stain showing similar fungal growths.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

In this case, a fungal colony was exposed in the pleural cavity from the pulmonary fistula that had caused the spontaneous pneumothorax, and culture examination of this fungal colony led to the diagnosis of CPA. Histopathological examination revealed that the fungus had infiltrated the wall of cavity formed by old tuberculosis, suggesting that it could be classified as an “aspergillus nodule” based on the definition of the European Respiratory Society, European Society of Clinical Microbiology and Infectious Diseases, and European Confederation of Medical Mycology joint guidelines [2016] (1). It is also possible that the case represented “subacute invasive pulmonary aspergillosis” as classified in the joint guidelines, given the presence of mild immunosuppression associated with oral corticosteroid therapy.

Pulmonary aspergillosis is known to be associated with pleurisy and pneumothorax; however, it is relatively uncommon for patients with pneumothorax as the initial manifestation being eventually diagnosed as having CPA (1,2). Furthermore, it has been reported that in many cases, the onset is influenced by a history of prior lung resection (2). In contrast, there are some reports of cases, including the present one, of spontaneous pneumothorax resulting from a cavity wall infection with Aspergillus species, independent of any history of lung resection (3-5). To the best of our knowledge, there have been no previous reports of thoracoscopic identification of aspergillus clusters causing CPA during a surgical procedure for pneumothorax (Figure 2), which is impressive for doctors involved in pneumothorax surgery. In addition to the present case, there have been reported cases of Aspergillus sp. infection in patients with immunocompromise caused by steroid administration (4,5). Long-term steroid administration is a risk factor for CPA exacerbation and Aspergillus infection could cause tissue destruction of a preexisting cyst wall (6,7). On the other hand, steroids themselves, due to their anti-inflammatory effects and fibrosis-inhibiting effect, may cause preexisting cyst walls to become fragile, potentially leading to the development of pneumothorax. Fungal infiltration of the cyst wall is also highly likely to cause tissue fragility and have a significant influence on the risk of development of pneumothorax.

In the present case, CPA, not suspected preoperatively, was diagnosed on the fifth postoperative day. Postoperatively, a review of the preoperative CT showed the presence of a nodule within a cyst (Figure 1D). However, because the lung was collapsed, it was difficult to identify the thick-walled cavities or fibrosis and parenchymal destruction which are hallmarks of CPA (1,8). If the presence of CPA had been suspected preoperatively, the surgical plan could have included resection of the fungal lesion, even if the pulmonary fistula was separate from the responsible lesion in the present case. Preoperative submission of blood specimens for aspergillus serology would have allowed earlier selection of the appropriate antifungal agent, even if it would have made a difference of only a few days. The patient had a history of old pulmonary tuberculosis, and it is believed that the aspergillus infection occurred in an old healed cystic lesion. As a result, the postoperative course of the patient was good, but considering that CPA is more likely to occur in patients with a history of old pulmonary tuberculosis (9,10), this is a point that should be reflected upon.

There is currently no consensus on the use of antifungal agents after lung resection surgery complicated by CPA. Although several previous reports have shown no significant benefit from postoperative antifungal therapy (11-13), recent reviews suggest that such therapy should be considered in cases of lung resection complicated by CPA, following complex procedures with a risk of spillage or in the presence of fungal elements invading the adjacent lung parenchyma (1,14). In this case, aspergillus clusters within the cyst were exposed to the thoracic cavity. Although the thoracic cavity was cleaned intraoperatively as in acute pyothorax, it could not be determined immediately after surgery if the thoracic cavity was completely sterile, so that we continued the patient on voriconazole treatment for 3 months after the surgery. As a result of this treatment, this elderly patient was cured without relapse despite being immunocompromised by steroid treatment. Further evidence needs to be collected to investigate the pros and cons of this treatment.

Conclusions

In patients with cystic changes in the lungs caused by old healed pulmonary tuberculosis who present with pneumothorax, the potential presence of CPA should also be considered. Even if the fungal colonies were exposed in the thoracic cavity during pneumothorax surgery, appropriate intraoperative and postoperative measures could allow even elderly steroid-treated patients to recover completely without recurrence of CPA.

Acknowledgments

We would like to thank International Medical Information Center Translation Section for English language editing.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-226/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-226/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-226/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Denning DW, Cadranel J, Beigelman-Aubry C, et al. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. Eur Respir J 2016;47:45-68. [Crossref] [PubMed]
2. Zhang J, Gao X-L, Wu J, et al. Clinical characteristics and outcomes of pleural aspergillosis: a review of 13 cases. Microbiol Spectr 2024;12:e0385223. [Crossref] [PubMed]
3. Sakuraba M, Sakao Y, Yamazaki A, et al. A case of aspergilloma detected after surgery for pneumothorax. Ann Thorac Cardiovasc Surg 2006;12:267-9.
4. Wong BK, Scott DJ. PNEUMOTHORAX: An Unusual Presentation of Aspergillosis. Proceedings of UCLA Health 2014;18:
5. Zhang W, Hu Y, Chen L, et al. Pleural aspergillosis complicated by recurrent pneumothorax: a case report. J Med Case Rep 2010;4:180. [Crossref] [PubMed]
6. Li Z, Denning DW. The Impact of Corticosteroids on the Outcome of Fungal Disease: a Systematic Review and Meta-analysis. Curr Fungal Infect Rep 2023;17:54-70. [Crossref] [PubMed]
7. Takeda K, Imamura Y, Takazono T, et al. The risk factors for developing of chronic pulmonary aspergillosis in nontuberculous mycobacteria patients and clinical characteristics and outcomes in chronic pulmonary aspergillosis patients coinfected with nontuberculous mycobacteria. Med Mycol 2016;54:120-7. [Crossref] [PubMed]
8. Sousa C, Pasini RA, Pasqualotto A, et al. Imaging Findings in Aspergillosis: From Head to Toe. Mycopathologia 2023;188:623-41. [Crossref] [PubMed]
9. Hedayati MT, Azimi Y, Droudinia A, et al. Prevalence of chronic pulmonary aspergillosis in patients with tuberculosis from Iran. Eur J Clin Microbiol Infect Dis 2015;34:1759-65. [Crossref] [PubMed]
10. Nguyen NTB, Le Ngoc H, Nguyen NV, et al. Chronic Pulmonary Aspergillosis Situation among Post Tuberculosis Patients in Vietnam: An Observational Study. J Fungi (Basel) 2021;7:532. [Crossref] [PubMed]
11. Benhamed L, Woelffle D. Adjuvant antifungal therapy after pulmonary surgery for aspergilloma: is it useful? Interact Cardiovasc Thorac Surg 2014;18:835-7. [Crossref] [PubMed]
12. Sagan D, Goździuk K. Surgery for pulmonary aspergilloma in immunocompetent patients: no benefit from adjuvant antifungal pharmacotherapy. Ann Thorac Surg 2010;89:1603-10. [Crossref] [PubMed]
13. Zheng S, Li X, Hu B, et al. Is adjuvant antifungal therapy after video-assisted thoracic surgery for pulmonary aspergilloma necessary? J Thorac Dis 2018;10:6060-5. [Crossref] [PubMed]
14. Lamoth F, Calandra T. Pulmonary aspergillosis: diagnosis and treatment. Eur Respir Rev 2022;31:220114. [Crossref] [PubMed]