A 67-year-old woman with a history of pulmonary tuberculosis treated for more than 40 years and chronic airflow limitation (LCFA), secondary to tuberculosis sequelae.
He did not smoke tobacco and had a history of having worked in agricultural work.
She was being treated for hypertension, complained of atopy, allergic reaction to acetaminophen and amoxicillin.
She had had recurrent respiratory infections and frequent exacerbations during the last five years, so she was being treated with salmeterol/ fluticasone (25/250 mcg), two inhalations twice a day and salbutamol.
He was referred to the respiratory diseases clinic of our hospital for presenting progressive dyspnea, persistent cough and hemoptysis for one year.
The functional assessment showed a decreased ejection fraction (FEV1) to 640 ml (33% of expected value) and forced vital capacity to 1,440 ml (55%) with no changes in bronchodilator use.
These values were similar to those obtained in previous studies.
A chest X-ray showed decreased lung volume, predominantly in the right hemithorax.
A chest CT scan showed multiple sclerosis and bilateral bronchiectasis, foci of asymmetrical cavity atelectasis, budding tree signs and fungal balls within some of the cavities.
Fiberoptic bronchoscopy was performed for microbiological study, and abundant purulent secretion was described throughout the bronchial tree.
During the procedure the patient presented an episode of dyspnea, oxygen desaturation, hypertensive crisis and general condition compromise.
She was assisted and, although she improved, she was hospitalized in the Emergency Unit.
1.
Upon admission she was wet, with blood pressure 160/100 mmHg, tachycardia 130 pulses per minute, tachypnea 28 breaths per minute and pulse oximetry 90% with environmental air.
On physical examination, pulmonary murmur decreased globally, abundant crepitations and diffuse wheezing.
Laboratory tests showed a leukocyte count of 15,200 cells/mm3, CRP 15 mg/dl (VN < 0.5 mg/dl) and hematocrit 3 .
Venturi mask ventilation was indicated in 28%, salbutamol nebulizations and respiratory physiotherapy were indicated.
Antimicrobial treatment with ceftriaxone i.v. was also initiated pending microbiological study.
In the lavage samples (BAL), Gram stain showed abundant amounts of Gram-positive cocci and Gomori-G staining revealed a large quantity of bronchoalveolar hyphae.
Ziehl-Neelsen stain showed no acid-fast bacilli.
In the bacterial culture there was development of Staphylococcus aureus sensitive to oxacillin at a concentration of 1 x 103/ml and in the culture there was abundant development of S. apiospermum.
Treatment was initiated with itraconazole 200 mg twice daily without anti-staphylococcal coverage.
The patient presented decreased dyspnea, hemoptysis and inflammatory activity indices and was discharged.
However, since the sixth week she presented cough with abundant bronchorrhea.
New expectoration cultures were requested, which were reported with abundant development of S. apiospermum, without bacterial growth and negative bacilloscopy.
Treatment was switched to voriconazole orally, 200 mg twice daily.
No loading dose was used and plasma concentrations could not be measured.
A total of 16 weeks of treatment was completed, with good clinical response and cultures of sputum without development.
Controlled six months after completing therapy, the patient presented with scarce cough, no bronchorrhea or hemoptysis and a significant decrease in dyspnea, which allowed him to resume his usual activities.
A partial reduction of the lesions was observed in the control lung CT; however, it was clinically in good general condition and without recurrence of the respiratory condition.
1.
Mycological study
BAL and expectoration samples were collected in Sabouraud agar at 37°C, where there was abundant development of a philosophies and filamentous base, initially white, annular.
Subsequently, it was transferred to potato dextrose agar (PDA), where at 25°C the colonies grew up to 50 mm in 14 days, grayish white cells with a single branched hycnoid base, with a greyish or non-typedified reversed, hair cells.
At three weeks of culture, the Graphium syna-namorph appeared at the ends of the colonies, gathering together with cyanophores 6 with pidioides, olive-coffee, smooth-cell mucosubhilar.
