A 61-year-old female who had never smoked was referred to Osaka University Hospital with a productive cough, shortness of breath, and wheezing for 5 years. She had a high eosinophil range of 6–20% (normal, 2–4%) and transient recurrent infiltrates on serial chest X-rays. Eosinophilic pneumonia with bronchial asthma had been diagnosed and treatment with oral prednisolone resulted in the remission of symptoms for 2–3 weeks at a time.\nThe patient complained of up to 10 mL of sputum per day which was purulent, malodorous and sometimes formed mucoid plugs. She was prescribed with inhaled corticosteroids and long-acting beta-agonists. She was found to have bilateral coarse crepitations with biphasic polyphonic rhonchi on pulmonary examination. Blood cell analysis revealed a total leukocyte count of 7240 cells/μL; with 44.7% polymorphs, 36.8% lymphocytes, 5.5% monocytes, 11.9% eosinophils, and 1.1% basophils. The absolute eosinophil count was elevated at 861/μL. Serum biochemistry findings were unremarkable, and Aspergillus spp. IgG antibody was negative. Total IgE was within the normal range (70.36 IU/mL), but specific IgE for Aspergillus spp. was found to be positive.\nA chest X-ray showed infiltrates in the right lower lung (A), and computed tomography revealed bilateral dilation of the central bronchi in the right upper lobe (B). The involved bronchi contained hyperattenuating mucus. Bilateral central bronchiectasis was diagnosed. The patient was further investigated because saccular bronchiectasis is a feature of allergic bronchopulmonary aspergillosis (ABPA). Direct analysis of sputum samples using random sequencing (shotgun sequence) using a next-generation sequencer revealed fungal DNA. Aspergillus fumigatus was dominant and four other fungal sequences including Schizophyllum commune were found ().\nMicroscopic assessment of sputum was negative for acid-fast bacilli (AFB) and other bacteria. However, Charcot–Leyden crystals that are generated through the breakdown of eosinophils and hyphae were identified (C and D). Direct microscopy of KOH wet mounts of three consecutive sputum specimens and expectorated sputum/mucoid plugs revealed two types of septate and branching hyphae (A and B). Homogenized sputum and mucoid plugs inoculated onto Sabouraud's glucose agar (SGA) developed green and white colonies with a wooly texture after 4 days at 2 °C (C and D).\nOne of the fungi was morphologically identified as A. fumigatus (A and C), but the other (B and D) remained obscure. Therefore, DNA was extracted and the internal transcribed spacer region (ITS) and the D1/D2 region of large subunit rRNA gene were amplified by PCR. Direct sequencing of the PCR products showed that the sequences of the ITS and D1/D2 regions were 100% similar to those of various S. commune strains, such as IFM 46097. The diagnosis of allergic bronchopulmonary mycosis (ABPM) due to co-infection with A. fumigatus and S. commune was made.\nThe susceptibility of the isolated A. fumigatus and S. commune strains to antifungal drugs (minimum inhibitory concentration; MIC) was as follows: amphotericin B (1 and 0.5 μg/mL), 5-fluorocytosine (64 and 0.25 μg/mL), fluconazole (>64 and 4 μg/mL), itraconazole (0.12 and 0.25 μg/mL), voriconazole (0.5 and 0.12 μg/mL), and micofungin (0.03 and >16 μg/mL), respectively.\nThe administration of oral itraconazole and prednisolone, improved the symptoms in this patient.
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).