Pleural aspergillosis in an otherwise healthy patient diagnosed by medical thoracoscopy

A 16-year-old boy presented to the emergency room complaining of right-sided chest discomfort and dyspnoea persisting for the past 10 days. Despite his previous good health, he had been hospitalized 3 months prior for fever and productive cough with yellowish phlegm. Diminished vocal fremitus and breath sounds were noted over the right chest. Chest computed tomography demonstrated right pneumothorax with blebs near the apex and diffuse pleural thickening (Fig. S1). Air and a small amount of purulent fluid were evacuated through closed thoracic drainage. The pleural effusion analysis revealed markedly elevated leukocyte count (white blood cell count, 1566 × 106/L), lactate dehydrogenase (5094 U/L), and adenosine deaminase (56.3 U/L), along with extremely low glucose levels (0.1 mmol/L), indicating a diagnosis of empyema. A single sequence of Aspergillus fumigatus was detected in the effusion through metagenomic next-generation sequencing, but was considered contaminated as β-D-glucan and galactomannan were both negative. Medical thoracoscopy was performed to investigate the underlying cause. Yellow, cheese-like lesions were visualized on the apical visceral pleura and the parietal pleura near the right diaphragm, accompanied by diffuse pleural thickening (Fig. 1). Tissue biopsy specimen histology revealed chronic granulomatous inflammation with hyphae resembling Aspergillus (Fig. 2). Tissue culture confirmed A fumigatus infection. Although recurrent pneumothorax had been reported as a potential aetiology [ 1 Abreu I. Guedes M. Duro R. Lopes S. Maciel J. Santos L. Pleural aspergillosis in a patient with recurrent spontaneous pneumothorax: the challenge of an optimal therapeutic approach. Med Mycol Case Rep. 2020; 28: 4-7https://doi.org/10.1016/j.mmcr.2020.02.004 Crossref PubMed Scopus (6) Google Scholar ], pleural aspergillosis is so uncommon in immunocompetent individuals that the initial diagnosis suggested by metagenomic next-generation sequencing was overlooked. The application of medical thoracoscopy and subsequent histological investigation played a pivotal role in establishing the diagnosis. Thoracoscopy has previously been considered as a viable therapeutic option [ 2 Ichikawa H. Doi R. Matsumoto K. Tomoshige K. Hirabaru M. Machino R. et al. Spontaneous pleural aspergillosis in an immunocompetent young adult treated with minimally invasive surgery. Respir Med Case Rep. 2023; 44101869https://doi.org/10.1016/j.rmcr.2023.101869 Crossref PubMed Scopus (1) Google Scholar ]. However, the patient was cured with administration of oral voriconazole and intrapleural amphotericin B. Fig. 2A tissue biopsy specimen revealed the presence of Aspergillus-like hyphae, stained with hematoxylin–eosin, the bar stands for (a) 625 μm or (b–d) 50μm. View Large Image Figure Viewer Download Hi-res image