Sinobronchial Allergic Mycosis: Case Report

A 17-year-old, African-American, male, high school athlete with mild intermittent asthma presented to the University of Mississippi Medical Center for the evaluation of chronic sinusitis. A physical examination demonstrated an edematous nasal mucosa, nasal polyps, and thick mucus. Bilateral wheezes were present on auscultation of the chest. Despite long-term antibiotic therapy and therapy with topical nasal steroids, his symptoms of nasal obstruction and intermittent purulent discharge persisted. A CT scan of the sinuses (Fig 1) revealed multiple soft-tissue densities causing total obstruction of both nares and opacification of the right frontal, ethmoid, maxillary, and sphenoid sinuses, with occlusion of the osteomeatal complex. Lateral bulging of the lamina papyracea of the right orbit and deviation of the nasal septum across the midline to the left were noted, and there was loss of bony margins of the right maxillary and ethmoid structures, which suggested pressure necrosis of cartilage. Buy ventolin inhaler this Areas of hyperattenuating radiodensity, a finding associated with fungal material within the sinuses, were noted within the sinuses on the right.
In preparation for endoscopic sinus surgery for probable AFS, a preoperative chest radiograph, the first one ever performed on the patient, was obtained. The radiograph appeared to show a large left-suprahilar mass and a right upper-lobe solitary pulmonary nodule (Fig 2). A helical CT scan of the chest revealed multiple bilateral pulmonary nodules with an upper lobe predominance and right hilar adenopathy with calcification. In the left lung field, a segmental bronchus demonstrated central saccular bronchiectasis, a radiologic hallmark of ABPM (Fig 3).
A minithoracotomy with an open-lung biopsy of the left upper-lobe mass was performed to confirm the diagnosis.
Figure 1. Coronal CT scan of the maxillary and ethmoid sinuses of our patient. There is total obstruction of both nares and opacification of the right ethmoid and maxillary sinuses. The bony margins of the ethmoid and maxillary sinuses on the left are poorly defined, with a slight bulging of the lamina papyracea component of the medial wall of the right orbit. The nasal septum is displaced to the left. There is mucoperiosteal thickening within the left ethmoid sinuses. Other views showed opacification of the right sphenoid sinus.
Figure 2. Erect posteroanterior chest radiograph of our patient showing diffuse peribronchial cuffing, an apparent left suprahilar mass, and a right upper-lobe solitary pulmonary nodule. The hilar findings, caused by massive mucous plugs, have previously been termed “pseudohilar adenopathy.”
Figure 3. A CT scan of the mid-upper lung fields in our patient showing central saccular bronchiectasis of a segmental bronchi on the left (arrow) and two pulmonary nodules on the right.

Category: Allergic

Tags: allergic bronchopulmonary mycosis, allergic fungal sinusitis, aspergillosis