A 76-year-old male presented to our institution with chronic cough and intermittent haemoptysis for 2 months. He had completed standard anti-TB therapy 10 years prior for smear positive cavitatory pulmonary Mycobacterium tuberculosis. Other past medical history was significant for rheumatic fever. He was a lifelong non-smoker. Thoracic computed tomography (CT) done 7 years previously demonstrated traction bronchiectasis and chronic scarring within the right upper lobe. He remained symptomatically well until this presentation.\nHis physical examination revealed bronchial breath sounds in the right upper lobe. Thoracic CT demonstrated fibrocystic change in an incompletely collapsed right upper lobe. There was now a large cavity with a new 2.1-cm round mass (Fig. A, C).\nWe proceeded to perform flexible bronchoscopy (Olympus 3.2 mm) under conscious sedation. After traversing two segments of the bronchi, an abnormal rounded mass was seen obstructing the anterior segment of the right upper lobe (Fig. A). Microbiological culture of bronchoalveolar lavage (BAL) from the right upper lobe cavity subsequently isolated both Staphylococcus aureus and Aspergillus fumigatus. He was commenced on a one week course of flucloxacillin as well as a prolonged course of the anti-fungal drug posaconazole. He was subsequently discharged and electively readmitted a few weeks later to facilitate bronchoscopic removal of the mycetoma.\nAt repeat flexible bronchoscopy, a flexible cryoprobe was inserted via the bronchoscope into the cavity. However, en bloc removal of the mass was not possible. The cryoprobe was removed and hot forceps was introduced to subdivide the mass into various smaller parts. Then the cryoprobe was reintroduced and the subdivided mass was removed piecemeal. Washing of the cavity was then performed with normal saline until all macroscopically visible mycetoma had been removed. Inspection of the empty cavity revealed inflamed haemorrhagic mucosa (Fig. B).\nThe obtained mass was sent for histopathological analysis. Microscopically, it demonstrated inflamed bronchial mucosa, abundant fungal organisms as well as a bacterial colony consistent with Gram-positive cocci. There was no evidence of invasive fungal infection. The case was discussed at our institution's multidisciplinary respiratory meeting, where a diagnosis of mycetoma was inferred. He was continued on oral posaconazole. Radiological and bronchoscopic surveillance at 3 months demonstrated no reoccurrence of the mycetoma (Figs. B, B, D).
A 38-year-old male presented with a cough for 3 days, hemoptysis, fevers, and chills for 1 day (). He denied cough, fevers, night sweats, or weight loss prior to 3 days before admission. He had emigrated to the U.S.A. from Mexico seven years previously and had no foreign travel subsequently. In his previous life, he had worked as an automobile mechanic, in construction, and gardening. His past medical history indicated treatment for a lung infection, with an inability to work, 9 years previously, but he did not recall the diagnosis. During that time, he was treated concurrently with 3 different types of medications for 7 months but was never told that he had tuberculosis. He had no history of risk factors for an anaerobic lung abscess, such as aspiration, alcohol use, smoking or seizures.\nOn admission, his temperature was 39.4°C, leukocyte count was 6500/mm3, and HIV test was negative. Therapy with piperacillin-tazobactam and vancomycin was initiated and the patient remained hospitalized for 2 weeks. Computed tomography of the lung on hospital day 2 demonstrated an 8.2 × 5.5 cm cystic structure in the left upper lobe with an internal air-fluid level, fluid debris levels and a thick, irregular wall, consistent with a pulmonary abscess. There were surrounding areas of “ground-glass” opacities and consolidation in the left upper and lower lobes. Sputum cultures grew methicillin-susceptible Staphylococcus aureus and Klebsiella oxytoca, prompting discontinuation of vancomycin on hospital day 8. On hospital day 9, transthoracic left upper lobe pulmonary abscess drainage was performed, with an aspiration of 140 cc of dark green–black fluid. Cytologic examination of the aspirated fluid did not show malignant cells, but had abundant neutrophils, numerous erythrocytes, and necrotic debris. Smear and culture for mycobacteria, and anaerobic culture, were negative. Fungal culture yielded two colonies of a filamentous non-sporulating fungus. The therapy was then switched to oral amoxicillin-clavulanate. At discharge, his cough had improved and he denied dyspnea.\nAfter discharge, he reported two weeks of mild intermittent dyspnea, but otherwise remained asymptomatic. The amoxicillin-clavulanate therapy was discontinued. However, serial chest radiographs demonstrated a persistent air-fluid level within a thin-walled cystic structure in the posterior left upper lobe. These radiographs were unchanged for four months. He reported two weeks of mild, intermittent dyspnea in the 4th-month post-discharge.\nA chest tomogram performed 5 months post-discharge, to better characterize the disease, revealed a thin-walled cystic cavity in the left upper lobe apical posterior segment, measuring 5.0 × 4.6 cm. The fluid within the lesion was hyperdense, and there was a calcified component posteriorly. Cephalad to the lesion, there was an architectural distortion and bronchiectasis with adjacent scarring and likely adjacent cicatricial emphysema. The oblique fissure was displaced anteriorly, posterior to this region, secondary to the associated volume loss and/or scar. There was less consolidation in this area compared to prior tomograms.\nA sputum bacterial culture was unremarkable, sputum smear for parasites was negative, as were antibody tests for Histoplasma, Coccidioides (IgG and IgM), and Echinococcus, and 2 blood cultures. A test for HIV was again negative. Sputum fungal culture grew Candida albicans and a filamentous fungus, morphologically similar to the previously isolated fungus. With a diagnosis of a persistent abscess, he proceeded to left upper lobectomy and extensive lysis of pleural adhesions. He was hospitalized 8 days, during which time he had intermittent fevers. Initially, there was a mild leukocytosis, which subsided. The intra-operative findings revealed an abscess that was located deep within the posterior aspect of the left upper lobe. The posterior fissure was completely fused and required extensive dissection. Intra-operative cultures were positive for a fungus, identified by sequencing as Gloeostereum sp. This was morphologically similar to the filamentous fungus that had been cultured on the previous occasions. Susceptibility testing of the fungus by macrobroth dilution indicated low MIC to amphotericin B (0.5 µg/ml), but high to voriconazole (MIC of >8 µg/ml) and fluconazole (MIC 16 µg/ml). Candida albicans was not cultured in the specimen, nor seen in the histopathology. No antifungal chemotherapy was given.\nHistopathology of the resected specimen was interpreted as chronic inflammation in a bronchogenic cyst with a lining of ciliated pseudostratified columnar epithelium, some muscle and fibrous tissue, subepithelial chronic inflammation and pulmonary congestion (). The cyst contents showed fungal hyphae (). The fungus was sent to the Westerdijk Fungal Biodiversity Institute for definitive speciation and deposited there under number CBS 145006. The patient was seen in clinic 2 weeks post-discharge, at which time he denied fevers, chills. He remained well in subsequent visits.