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 50-year-old female, with history of allergic rhinitis, presented with nasal obstruction, purulent nasal discharge from right side, cough, headache, and sneezing. She had completed a 10-day course of doxycycline with minimal symptomatic improvement. She was not a known case of diabetes, hypertension, bronchial asthma, or pulmonary tuberculosis. There was no history of previous surgery, facial trauma, distant travel, or drug abuse. On physical examination, a purulent discharge was noted in the right middle meatus. The left middle meatus was clear. The remaining examination of the head and neck revealed no significant findings. Her hemoglobin was 15.3 g/liter, her hematocrit was 0.45, and the leukocyte count was 7.4 × 109/liter with a normal leukocyte differential. The chest X-ray was unremarkable. A bone density-computed tomography revealed extensive opacity of the right maxillary sinus as well as erosion of the nasal wall and maxillary bone. The patient underwent right-sided functional endoscopic sinus surgery with opening of the right maxillary sinus. Thick mucus was present in the right maxillary sinus. The material was removed and sent for culture and histological examination. No antifungal agents were prescribed at that point in time. After 5 days, the patient came with complaint of bleeding from the right nostril. Right nostril was packed using a roller gauze and left nostril with IVALON nasal pack. Clots were visualized in B/L maxillary antrum using 30-degree scope, which were suctioned out. Mucosa was found to be healthy. No active anterior or posterior nasal bleeding. Patient was stable and asymptomatic and discharged.\nSpecimens sent for histological studies showed extensive eosinophilic infiltration with Charcot-Leyden crystals. There was no tissue invasion. Examination after Periodic Acid Schiff (PAS) staining showed septate, nondichotomously branching fungal hyphae (). Direct microscopy of a KOH preparation of the surgical specimen showed the presence of hyaline septate hyphae (). Culture at 27°C and 37°C on Sabouraud's dextrose agar containing gentamicin yielded a rapidly growing, white to pale buff, densely woolly fungus with a pale-brown reverse. It produced a strong disagreeable odor. There was no growth on medium containing cycloheximide. No bacteria were isolated under aerobic or anaerobic conditions. Microscopic examination of the mold showed hyphae of various widths. The isolate was held for several months and subcultured on different media, but it failed to sporulate under any conditions. Banana peel culture after 8 weeks showed macroscopically visible fan-shaped fruiting bodies (). LPCB mount of the same revealed hyaline septate hyphae, often with clamp connections or lateral pegs (, inset). Identification was confirmed by the presence of clamp connections formed on the hyphae and by vegetative compatibility with known isolates. Further study showed the isolate to be tolerant of benomyl (2 μg/mL), consistent with this basidiomycete [].