Allergic bronchopulmonary mycosis presenting as a new lung mass.

Landaeta M, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221591 Description A 69-year-old man with invasive pancreatic ductal adenocarcinoma underwent pancreaticoduodenectomy and adjuvant chemotherapy. Three years later, a right upper lobe (RUL) lung mass was noted on surveillance imaging, suspicious for disease recurrence. He was treated for bronchitis and remained asymptomatic 4 months later with an unremarkable physical exam. Chest imaging (figure 1A,B) showed an RUL central mass with an infiltrative pattern of growth and right paratracheal adenopathy that is negative for malignancy on endobronchial ultrasound-guided needle aspiration. Bronchoalveolar lavage and brushing grew branching septate hyphae identified as Bipolaris species. The presence of cylindrical bronchiectasis with bronchial wall thickening, mucus plugging, peripheral eosinophilia (810 cells/μL), elevated total serum immunoglobulin E (422.6 IU/mL) and negative aspergillus antibodies suggested allergic bronchopulmonary mycosis (ABPM) caused by Bipolaris species. After 3 months of therapy with prednisone and posaconazole, the mass-like consolidation was completely resolved (figure 1C,D). ABPM is a pulmonary hypersensitivity disease induced by colonisation of a fungus in the airways. While commonly attributed to Aspergillus species, other fungi including Bipolaris have been reported to cause ABPM. In our case, ABPM, a rare disease, was mimicking metastatic lung disease. The approach to emerging lung masses in patients with cancer undergoing surveillance remains a challenge. While cancer recurrence is invariably the focus of attention, clinicians should be aware of the differential diagnosis for new lung masses. A primary lung malignancy should always be considered in addition to non-malignant aetiologies such as fungal and mycobacterial infections, radiotherapy side effects and granulomatous diseases.