Aspergilloma in a cavitary rheumatic pulmonary nodule

Abstract

A 67-year-old ex-smoker hypertensive male, on antituberculous therapy for the last 9 months for clinically diagnosed pulmonary tuberculosis (PTB), was referred to our clinic as a suspected case of drug resistant tuberculosis (DR-TB) due to the increasing cavity size and his progressive breathlessness. He was never bacteriologically positive for PTB either by smear or culture. A review of his history, subsequent investigations, and serial chest x-rays and high resolution computed tomography (HRCT) led to a suspicion of rheumatoid arthritis (RA) with pulmonary involvement. Although earlier x-rays showed increasing size of the cavity and thickening of the wall, the latest x-ray showed a well-formed air crescent sign. Further investigations revealed positive rheumatoid factor (RF), anti-nuclear antibodies (ANA), serum precipitin for Aspergillus fumigatus along with raised specific IgE. Contrast-Enhanced Computed Tomography (CECT) of the chest showed an interstitial lung disease (ILD) pattern and a cavity with a soft tissue collection along its wall. A diagnosis of RA with ILD and cavitating rheumatoid nodule developing aspergilloma was made, which is uncommon and can be easily missed by clinicians.

Keywords: Aspergilloma, rheumatic nodules, tuberculosis, rheumatoid lung disease