Pleural Aspergillosis in an otherwise healthy individual
A 16-year-old Indian boy presented to the out-patient department of our hospital with complaints of low-grade fever, dry cough and left sided chest discomfort of 6 weeks duration. Cough was non-productive, non-spasmodic without postural or diurnal variation. The chest pain was worse on coughing. There was no history of similar complaints in the past. He had no history of hemoptysis, loss of appetite or weight loss. There was no history of bronchial asthma, diabetes mellitus, previous hospitalization or surgical intervention. On examination, patient was of fair nutritional status and his vitals were stable. General physical examination did not reveal any significant abnormality. On chest examination, left sided movements were decreased, percussion note was stony dull and air entry was absent. Succusion splash was also heard. On investigating, his routine hematological and biochemical parameters were normal (hemoglobin – 11 g/dl, total leucocyte count – 7600/cc, differential leucocyte count – P52 L40E8, blood sugar (fasting) – 86 mg/dl, blood sugar (post-prandial) – 148 mg/dl, T. bilirubin-0.4 mg/dl, aspartate aminotransferase - 26 IU/ml, alanine aminotrans ferase 38 IU/ml, blood.urea-26 mg/dl, S. creatinine-1.0 mg/dl). Mantoux test and serology for human immunodeficiency virus were negative. Immunoglobulin E was significantly elevated (1602 IU/ml). A chest radiograph was done, which had features of left pyopneumothorax. Air fluid level was present on the radiograph []. Diagnostic intercostal drainage revealed frank brownish pus and tube thoracostomy was performed draining 1000 ml pus on the 1st day itself. The pus and induced sputum stained negative for pyogenic organisms and acid fast bacilli (AFB). Considering the fact that the patient belonged to a high incidence area for tuberculosis, a therapeutic trial of anti-tuberculosis treatment was started. However, at the end of 2 months of treatment, his induced sputum and pleural fluid again stained negative for AFB. Culture of the sputum sample was also negative for AFB. Despite treatment and drainage with a broad intercostal drainage tube (ICD) his symptoms failed to resolve. The sputum and pus were then subjected to fungal smears and culture. The sputum smears were negative, but pus smears showed septate fungal hyphae and grew A. fumigatus in culture []. Smears from the culture showed septate hyphae and conidiophores confirming pathogenic role of the mould. Flexible bronchoscopy was done and bronchial wash was subjected to microbiological studies. Both fungal smear and culture were negative, indicating lack of pulmonary involvement. Patient was thus diagnosed as pleural Aspergillosis in the absence of invasive pulmonary Aspergillosis or any other obvious predisposing factors. He was started on voriconazole 300 mg twice-a-day. Within 4 weeks, the patient showed signs of recovery with reduction in cough and chest pain []. The pyopneumothorax showed signs of resolution and the ICD was removed after 6 weeks of starting treatment. Patient was maintained on oral voriconazole for 9 months and showed no signs of relapse 1 year later.\nWe conducted a thorough search for the source of the A. fumigatus infection in our patient and found that the boy had a carious tooth. On culture in blood agar, Streptomyces spp. was grown. In addition, the carious material was cultured in Sabouraud's Dextrose Agar medium and it grew A. fumigatus. We thus hypothesize that at some point in time the patient could possibly have aspirated the carious material, which would have infected the pleura subsequently without direct invasion of lung parenchyma. We thus, report this case in view of the extreme rarity of pleural Aspergillosis in patients with otherwise healthy lungs.