Pulmonary Aspergilloma: A Treatment Challenge in Sub-Saharan Africa

In April 2011, a 68-year-old man presented himself at our research clinic in rural Tanzania with a three-month persistent productive cough, chest pain, night sweats, and recurrent nonmassive haemoptysis. He denied fever, night sweats, weight loss, and any recent contact with a known tuberculosis case. A prior treatment with a broadspectrum antibiotic had not been successful. The patient reported having been treated for tuberculosis, diagnosed by sputum smear ten years ago. On examination he was afebrile, in a reduced general condition with a body mass index of 17.1 kg/m. Other findings were bilateral reduced breath sounds and mild clubbing. Testing for HIV with two rapid tests (SD Bioline HIV 1/2 3.0 and Determine HIV-1/2) was negative. Posteroanterior chest radiography in an erect position showed a cavity of 60 mm673 mm diameter in the right upper lobe containing an intracavitary focal mass of 47 mm631 mm diameter with adjacent moon-shaped radiolucency (Figure 1). A second radiography in a supine position showed a changed position of this focal mass (Figure 2). A chest x-ray of the previous TB episode was not available for comparison. Smear microscopy of early morning and spot sputum after Ziehl-Neelsen stain was negative for acid-fast bacilli. A nucleic acid amplification test (Xpert MTB/RIF) did not detect Mycobacterium tuberculosis. Both the early morning and spot sputum samples were subsequently cultured on solid (Lowenstein Jensen) and in liquid (MGIT) media, neither of which showed mycobacterial growth after eight and six weeks, respectively. In order to isolate Aspergillus, a sabouraud dextrose agar was inoculated directly with sputum, but only Enterobacter cloacae could be found. Due to lack of facilities, neither an ELISA for IgG antibodies to Aspergillus nor an Aspergillus precipitin test could be performed. Based on radiographies, a diagnosis of single pulmonary aspergilloma was established, but we could not exclude that the symptoms were caused by tuberculosis reactivation or reinfection. With negative sputum smears, chest radiography findings consistent with tuberculosis, and a lack of response to a trial broad-spectrum antimicrobial agent, our patient fulfilled the WHO criteria for sputum smear–negative tuberculosis. Without options for surgical treatment of pulmonary aspergilloma, we were now faced with the decision of either starting medication for pulmonary aspergilloma or sending the patient for tuberculosis treatment. Considering unavailability of sputum culture results at this point and our setting with high prevalence of tuberculosis, we presented the case to the National Tuberculosis and Leprosy Program (NTLP) which initiated six-month standard tuberculosis treatment according to national guidelines, which implies prescription of rifampin, isoniazid, ethambutol, and pyrazinamide for two months, followed by rifampin and isoniazid for four months. After six months of antituberculosis therapy, the patient was still in a reduced condition, complaining about productive cough and chest pain, but no haemoptysis or night sweats. His body mass index had increased to 19.2 kg/m. Radiographies, however, did not show any improvement. Because of the persistent symptomology, the patient was subsequently started on antifungal treatment with itraconazole 200 mg daily for six months. At the end of this period, the treatment was extended for another six months because the patient had reported that the dispensary had not been able to provide him with medication continuously and therefore he had not been able to take medication for the last three months of treatment. At the last follow-up in October 2012 we noticed a clinical improvement of the chest pain and no productive cough despite a follow-up radiography not showing any changes.