case_images: PMC10951711_01
case_images: Clinical course on chest images and PFT (A) Chest radiograph at year -6 shows ill-defined consolidation, nodules, and opacities along the bronchus in the left upper lobe, accompanied by bronchial wall thickening. (B) Chest CT at year -6 shows no apparent intratracheal lesions in the right lower lung lobe. (C) Chest radiograph at day -30 shows significant improvement in the consolidation in the left upper lung lobe. However, irregular opacities around the truncus intermedius and elevation of the diaphragm on the right side are observed. (D) Chest CT at day -30 shows constriction of the lumen of the truncus basalis. (E) Chest radiograph on day 0 shows right basilar opacities with volume loss and further elevation of the diaphragm on the right side. (F) Chest CT on day 0 shows complete occlusion of the truncus basalis with a low-density area containing mucus at the center of the occluded lesion. (G) Chest radiograph on day +15 shows improved right basilar opacities and a partial reduction in the diaphragm elevation on the right side. (H) Chest CT on day +15 shows an endobronchial soft tissue nodule in the truncus basalis without a low-density area. (I) Chest radiograph at + 8 months shows no new lesions. Although linear and reticular shadows persist, the right lower lobe bronchus is preserved. (J) Chest CT at + 8 months shows complete resolution of the obstruction in the truncus basalis of the right bronchial lumen. (K) PFTs conducted two months after omalizumab initiation reveal an FEV1% of 65.3%, with an FEV1 of 3.03 L. On day -30, PFTs reveal an FEV1% of 72.1% and an FEV1 of 2.89 (L) On day +15, FEV1% and FEV1 are 73.6% and 2.67 L, respectively. At +8 months, the FEV1% and FEV1 values have improved to 76.8% and 3.07 L, respectively. Abbreviations: CT, computed tomography; PFT, pulmonary function test; ITCZ, itraconazole; AMPC/CVA, amoxicillin-clavulanate; FEV1%, forced expiratory volume in one second as a percent of forced vital capacity; FEV1, forced expiratory volume in one second.
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case_images: ABPA based on the following findings: high attenuation mucus in the left upper lobe bronchus on chest computed tomography (CT); an Aspergillus fumigatus-specific IgE level of 5.30 kUA/L, a serum total IgE level of 802 kU/L, a white blood cell count of 6910/muL, and an eosinophil count of 988/muL on hematological examination; Charcot-Leyden crystals with numerous eosinophils in the mucus on sputum cytology; and a positive sputum culture for Aspergillus fumigatus. After the diagnosis of ABPA was confirmed, the patient initially received omalizumab (600 mg subcutaneously every other week) because prednisolone caused insomnia (Fig. 1, Fig. 2). Chest CT on day -30 revealed a collapsed lumen of the truncus basalis with slight atelectasis (Fig. 1D); therefore, further examination was planned. Chest radiography revealed right basilar consolidation, opacities, and diaphragmatic elevation (Fig. 1E). Chest CT revealed complete occlusion of the truncus basalis, with a central low-density area containing mucus (Fig. 1F). Additionally, chest radiography showed persistence of right basilar opacities with slight volume loss, linear shadows, reticular shadows, and right-sided diaphragmatic elevation (Fig. 1G). Furthermore, chest CT revealed an endobronchial soft-tissue nodule in the truncus basalis with peripheral atelectasis (Fig. 1H). Flexible bronchoscopy on day +45 (Fig. 1G and H) revealed an obstructing smooth nodule in the truncus basalis, surrounded by purulent mucus (Fig. 2A). All test results at +8 months showed improvement (Fig. 1, Fig. 2D).
case_images: Bronchoscopic and histopathological findings (A) Bronchoscopic image (day +45) showing almost complete occlusion of the right truncus basalis by a smooth nodule surrounded by purulent mucus. Aspergillus fumigatus was cultured from the purulent mucus. (B) Two weeks after EBFB (day +60), a smooth pedunculated nodule obstructing the right B7 persists. (C) The nodule at the right B7 is removed using biopsy forceps. The bronchial mucosa on the mediastinal side of the biopsy forceps shows edema and redness owing to the previous nodule removal. (D) Bronchoscopic findings from the same angle as (A) at +8 months. The bronchial lumen shows improvement in edema of the bronchial mucosa due to nodule removal and no new lesions. (E), (F) Sputum cytology six years prior to flexible bronchoscopic intervention shows Charcot-Leyden crystals (Giemsa staining; F) with numerous eosinophils in the mucus (E). (G) and (H) Histopathological examination of the nodule shows the proliferation of inflammatory cells, predominantly lymphocytes and plasma cells, along with few fibroblasts. No atypical cells are observed. (G) Low- and (H) high-magnification images (hematoxylin and eosin stain). Abbreviations: EBFB, endobronchial forceps biopsy.
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case_images: No atypical cells were observed, consistent with inflammatory granulomas (Fig. 2G and H). Owing to the residual symptoms, a second bronchoscopic procedure was performed on day +60, which revealed a residual smooth pedunculated nodule obstructing the right B7 (Fig. 2B). An endobronchial forceps biopsy (EBFB) was performed (Fig. 2C), and the histopathological findings were consistent with the previous results, confirming the diagnosis of IEP.