Multidrug resistant tuberculosis co-existing with aspergilloma and invasive aspergillosis in a 50 year old diabetic woman: a case report
© Kumar et al; licensee BioMed Central Ltd. 2008
Received: 13 October 2008
Accepted: 08 November 2008
Published: 08 November 2008
Aspergilloma and invasive aspergillosis coexisting with multidrug resistant Mycobacterium tuberculosis (MDR-TB) in the same patient is a rare entity. We report a 50 year old South Indian woman, a diabetic, who presented to us with complaints of productive cough and hemoptysis for the past 2 months. She was diagnosed to have pulmonary tuberculosis 2 years ago for which she took irregular treatment. Lung imaging showed features of a thick walled cavity in the right upper lobe with an indwelling aspergilloma. She underwent a right lung upper lobe resection. Biopsy and culture of the resected specimen showed the coexistence of Aspergillus fumigatus and multi-drug resistant Mycobacterium tuberculosis. 2 blood cultures grew Aspergillus fumigatus. She was successfully treated with Voriconazole and anti tuberculous therapy against MDR-TB.
Pulmonary tuberculosis is the most commonly associated disease in cases of secondary aspergilloma . Generally aspergilloma is seen residing in an old tuberculous cavity. In this case report we present a rare case of an aspergilloma co-existing with multidrug resistant mycobacterium tuberculous in an old cavity. This patient also had invasive aspergillosis. This combination is uncommon and to the best of our knowledge is not reported in literature.
Hemoglobin 7 g/dl
Poly morphs: 73%
Total serum bilirubin
Random blood sugar
ELISA for HIV 1 and 2
non – reactive
Sputum AFB (3 samples)
Mycobacterium tuberculosis (MDR-TB)
Blood culture (2 samples)
TB is principally a disease of poverty, with 95% of cases and 98% of deaths occurring in developing countries. Of these, more than half the cases occur in five South-East Asian countries . Globally, about 3% of all newly diagnosed patients have MDR-TB . Definition of multi-drug resistance refers to isolates resistant to both Isoniazid and Rifampicin with or without resistance to other drugs . Three common forms of pulmonary disease associated with Aspergillus infection has been described, namely, allergic aspergillosis, colonizing aspergillosis, and invasive aspergillosis. A study showed that aspergilloma was commonly associated with pulmonary tuberculosis and affected the upper lobes in 94% of the cases . Our patient also had pulmonary tuberculosis and aspergilloma had affected the right upper lobe. The uniqueness of our case report is that this association between MDR-TB, aspergilloma and invasive aspergillosis in the same patient is rare and to the best of our knowledge has not been reported in the literature before.
The natural history of aspergilloma is variable. Hemoptysis is the commonest mode of presentation, with an incidence of around 80%, which is life threatening in 30% . In the majority of cases, the lesion remains stable, however, in approximately 10% of cases, it may decrease in size or resolve spontaneously without treatment . Rarely, the aspergilloma increases in size . Predicted mortality due to aspergilloma is reported at a rate of 6% per annum . Surgery not only offers symptomatic control but also confers survival advantage . Hemoptysis completely resolved in our patient after right lung upper lobe resection. Invasive aspergillosis is commonly seen in immunocompromised patients. Except for the poorly controlled diabetes, we could not identify any other risk factor for invasive fungal infection in our patient.
Aspergilloma, invasive aspergillosis, and MDR-TB can coexist in the same patient. Hence patients who have a recurrence of tuberculosis, and who were previous defaulters of antitubercular therapy, an AFB culture should be performed in order to identify MDR-TB. Surgery often gives good results in the treatment of aspergilloma. Systemic antifungals should be administered against invasive fungal infections.
I have realized my mistake of stopping the TB medicines. Now the treatment is prolonged and the injection is painful. I could have spread these resistant bacteria to many people. Hence forth I will be careful and follow my doctor's instructions. I have learnt my lesson for sure but in a hard way.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Multi-Drug Resistant Tuberculosis
Acid Fast Bacillus
World Health Organization.
- Sugar AM, Olek EA: Diagnosis of Aspergilloma. FishmanÕs Pulmonary Diseases and Disorders. Edited by: Fishman AP, Elisa JA. 1998, USA. McGraw Hill Companies, 2272-78. 3Google Scholar
- Geist MJ, Egerer G, Burhenne J, Riedel KD, Mikus G: Induction of voriconazole metabolism by rifampin in a patient with acute myeloid leukemia: importance of interdisciplinary communication to prevent treatment errors with complex medications. Antimicrob Agents Chemother. 2007, 51 (9): 3455-6. 10.1128/AAC.00579-07. Epub 2007 Jul 2.PubMed CentralView ArticlePubMedGoogle Scholar
- World Health Organisation: Treatment for tuberculosis. Guidelines for national programmes. 2003, Geneva: World Health Organisation, (WHO/CDS/TB/2003.313)., 3Google Scholar
- Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC: Consensus statement. Global burden of tuberculosis: estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring project. JAMA. 1999, 282: 677-86. 10.1001/jama.282.7.677.View ArticlePubMedGoogle Scholar
- Sharma SK, Mohan A: Multi-drug resistant tuberculosis. Review article. Indian J Med Res. 2004, 120: 354-376.PubMedGoogle Scholar
- Garrós Garay J, Ruiz de Gordejuela E, Vara Quadrado F: Pulmonary aspergillomas. Analysis of 31 patients. Arch Bronconeumol. 1994, 30 (9): 424-32.View ArticlePubMedGoogle Scholar
- Vaideeswar P, Prasad S, Deshpande JR, Pandit SP: Invasive pulmonary aspergillosis: A study of 39 cases at autopsy. J Postgrad Med. 2004, 50: 21-6.PubMedGoogle Scholar
- Gefter WB: The spectrum of pulmonary aspergillosis. J Thorac Imaging. 1992, 7: 56-74.View ArticlePubMedGoogle Scholar
- British Tuberculosis Association: Aspergillus in persistent lung cavities after tuberculosis: a report from the Research Committee of the British Tuberculosis Association. Tubercle. 1968, 49: 1-11. 10.1016/S0041-3879(68)80002-9.View ArticleGoogle Scholar
- British Thoracic and Tuberculosis Association: Aspergilloma and residual tuberculous cavities: the results of re-survey. Tubercle. 1970, 51: 227-45. 10.1016/0041-3879(70)90015-2.View ArticleGoogle Scholar
- Ueda H, Okabayashi K, Ondo K, Motohiro A: Analysis of various treatment for pulmonary aspergillomas. Surg Today. 2001, 31: 768-73. 10.1007/s005950170045.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.