CHRONIC CAVITARY PULMONAR...

A 17-year-old girl presented to the outpatient department with complaints of cough with copious, mucoid, white sputum associated with shortness of breath grade 3 mMRC ,persistent in nature, associated with wheezing for three months. Patient complaints of fever for three months which was low grade, intermittent, not associated with chills and rigors, relieved with medications. History of loss of appetite and loss of weight present. History of expectoration of brown-coloured mucus plugs. The patient had complaints of loss of appetite and loss of weight nine months back associated with cough and expectoration for which she was initiated on antitubercular therapy by the private practitioner for six months following which she did not have any improvement in the symptoms. No history of hemoptysis or chest pain. No history of smoking, biomass exposure,allergy, or occupational exposure to dust. No history of any other associated co-morbidities. History of drooping of the left upper eyelid since three months. On examination, the patient was pale with no icterus, clubbing, cyanosis, lymphadenopathy, and pedal edema. The Left eye was sunken into the eyeball cavity(enophthalmos)with drooping of the eyelid(ptosis), constricted pupil(miosis), and reduced sweating of the left face. On inspection, the patient was tachypneic and tachycardic with bilateral equal chest movements and bilaterally symmetrical chest with the use of accessory muscles of respiration. On palpation, the apex beat was normal in place. All inspectory findings were confirmed. On percussion, bilateral resonant note was encountered over all the areas. On auscultation, cavernous bronchial breathing was appreciated over the left suprascapular and infraclavicular area. Chest x-ray showed multiple bilateral cavitary lesions. Complete blood count showed eosinophilia with AEC count 750. The patient was further evaluated with HRCT thorax in which bilateral cavitary lesions were found which was not invasive. MRI of the brain was done to rule out any pathology causing Horner’s syndrome. HRCT revealed multiple bilateral cavitary lesions with central bronchiectasis with left upper lobe cystic lesion suggestive of chronic cavitory pulmonary aspergilosis and granuloma in the left hypothalamus on C-MRI brain. Ultrasound abdomen was done to rule out cystic lesions in the liver which was within normal limits. The above findings suggested that the respiratory symptoms are attributed to respiratory pathology and Horner’s syndrome was attributed to pathology in the hypothalamus. The patient was evaluated for total IgE levels and IgE against Aspergillus fumigatus which were elevated, serum precipitins for Aspergillus fumigatus was positive, presence of multiple colonies of Aspergillus fumigatus on fungal culture which was suggestive of chronic cavitary pulmonary aspergillosis. Active pulmonary Tuberculosis was ruled out by doing sputum CBNAAT and AFB culture. The patient was negative for pANCA and cANCA to rule out vasculitis. The patient was treated for chronic cavitary pulmonary aspergillosis with antifungals, bronchodilators, and LTRA. FINAL DIAGNOSIS: CHRONIC CAVITARY PULMONARY ASPERGILLOSIS WITH HORNER’S SYNDROME.