A 61 year-old Female with a Prior History of Tuberculosis Presenting with Hemoptysis

Diagnosis: Chronic Necrotizing Pulmonary Scedosporiosis. Heavy growth of Scedosporium apiospermum was obtained from expectorated sputum and bronchoalveolar lavage samples. These cultures had positive results repeatedly over the course of several months. This, in combination with the patient’s clinical picture and imaging findings, supports a diagnosis of chronic necrotizing pulmonary S. apiospermum infection. Chronic necrotizing pulmonary mycotic infection is a relatively rare disease that is gaining appreciation in the literature as a distinct clinical entity. It is almost exclusively described in patients with Aspergillus infections, referred to as chronic necrotizing pulmonary aspergillosis (CNPA). Here we report a similar disease process caused by another filamentous fungus, S. apiospermum. S. apiospermum (sexual form, Pseudoallescheria boydii) is an opportunistic filamentous fungus that can be isolated from soil and contaminated water sources. It is found in temperate climate regions worldwide. The other major genus member, Scedosporium prolificans, is restricted to Australia, Spain, Portugal, and the southern United States, as well as California [1]. On the basis of clinical, radiographic, and histopathologic features, Scedosporium species can be virtually indistinguishable from Aspergillus species; however, management presents unique challenges. Like Aspergillus species, S. apiospermum causes a wide spectrum of pulmonary disease ranging from allergic bronchopulmonary mycosis to uncomplicated fungal balls to more extensive cavitary disease with or without angioinvasion [1]. Within this disease spectrum, our patient presented with a semi-invasive chronic necrotizing pulmonary infection akin to CNPA. Typical presenting symptoms include chronic cough and intermittent hemoptysis. Systemic symptoms, such as fever and weight loss, are less common. Risk factors include moderate immunosuppression, such as that caused by diabetes mellitus or corticosteroid use [2–5]. This is in contrast to patients with invasive pulmonary mycoses and/or disseminated disease who are profoundly immunosuppressed as a result of solid-organ transplant, bone marrow transplant, or AIDS [6–8]. Previous lung damage with underlying cavitary disease is extremely common. In the largest series to date of patients with CNPA, more than 90% of patients had a prior history of mycobacterial disease [5]. In this series, the most common imaging Figure 1. Axial (A) and coronal maximum intensity projection (B) images from a contrast-enhanced computed tomographic scan of the chest show numerous cavities with indwelling fungal balls (white arrows), as well as bronchiectasis (black arrows).