Aspergillus fumigatus fungus ball in the native lung after single lung transplantation

Bola fúngica por Aspergillus fumigatus no pulmão nativo após transplante unilateral de pulmão A 49-year-old woman underwent right lung transplantation due to pulmonary emphysema, with favorable evolution in the early postoperative period. A year later she was readmitted to our department with productive cough. During that admission, the patient was treated for cytomegalovirus pneumonia and received broad-spectrum antibacterial therapy. At outpatient follow-up, cavities appeared in the native lung, which gradually increased in size. Ten months later, she was admitted for the resection of a hyperinflated cavity. Chest X-rays showed an increase in the cavity in the left upper lobe with herniation of the lung and compression of the transplanted lung. Chest HRCT at various positions showed a round mass with soft tissue density within a lung cavity that moved when the patient changed position, thus strengthening the hypothesis of a fungus ball (Figure 1). Bullectomy was performed, and the histopathologic examination showed fungal colonization by Aspergillus fumigatus in emphysematous bullae and bronchiectasis. She was treated with itraconazole and had a satisfactory response. Lung transplantation has become an acceptable treatment option for many end-stage lung diseases and could be single or double. However, Aspergillus sp. infections continue to be an important cause of morbidity and mortality in these patients. Aspergillus sp. is an ubiquitous fungus that can cause clinical entities of varying severity, such as asymptomatic colonization, aspergilloma, tracheobronchitis, active parenchymal disease, and angioinvasive aspergillosis. Airway colonization is a common occurrence in such patients because of the exposure of the transplanted lung to the environment and impaired local host defenses, including mucociliary clearance. In addition, colonization of the native lung, which commonly occurs in end-stage lung disease, is an important source of post-transplantation aspergillosis in single lung transplantation recipients. Aspergillus sp. colonization has also been related to cytomegalovirus infection and chronic rejection. Patients who undergo unilateral transplantation are often older and have a higher prevalence of COPD as an underlying disease, a condition that might predispose to airway colonization by Aspergillus sp. The most accurate way to perform the diagnosis is the demonstration of characteristic, acute branching, broad, septate hyphae showing zones of growth in biopsy/surgical/autopsy specimens and positive cultures for Aspergillus sp. Our patient presented with Aspergillus fumigatus fungal ball (aspergilloma) in emphysematous bullae and bronchiectasis in the native lung 26 months after transplantation, with a satisfactory response to medical and surgical treatment. She also had a history of cytomegalovirus …