A 73-year-old man presented to the ER with dyspnoea, cough with purulent sputum and weight loss. The patient lived alone with poor hygiene conditions and a history of smoking and excessive alcohol consumption.
The patient was malnourished, dehydrated, polypneic and hypotensive. The pulmonary auscultation revealed a symmetric vesicular murmur with bilateral wheezing and fine crackles. The chest X-ray showed a bilateral reticulonodular pattern in the apical region of both lungs (Fig. 1A). An high white blood cell count (19993×106/L, neutrophils 88.6%) and elevated PCR (10.6mg/dL) were present. The chest CT scan revealed marked structural disruption of both lungs with multiple cystic cavities, the largest ones on both apex containing solid material (Fig. 1B–D).
After the admission a bronchoscopy was performed with a bronchoalveolar lavage fluid (BALF) negative-smear for acid-fast bacilli. However, the pneumonologist advised on initiating tuberculostatic treatment on empirical basis.
On the seventh day, the culture of BALF isolated an Aspergillus fumigatus and Haemophilus influenzae biotype III. Itraconazole was started but the patient did not respond to treatment. He developed acute respiratory failure and died.
