Pulmonary tuberculosis is one of the most common immunosuppressive infections in India, seldom accompanies other parasitic and fungal infections. In our case, we describe the three coexistent infections and their clinical presentation in a 53-year-old woman. A fibro-cavitary lesion in lung with superadded infections of hydatid cyst and aspergillus which is rare has been elaborated in the present case.
Keywords: Aspergillus, hydatid cyst, lung, tuberculosis
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Kartavya K V, Rajul B, Nighat H, Kashyap N, Amrutha G. Pulmonary tuberculosis with superadded infection of echinococcus and aspergillus. Indian J Pathol Microbiol 2022;65:472-4
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Kartavya K V, Rajul B, Nighat H, Kashyap N, Amrutha G. Pulmonary tuberculosis with superadded infection of echinococcus and aspergillus. Indian J Pathol Microbiol [serial online] 2022 [cited 2022 May 5];65:472-4. Available from: https://www.ijpmonline.org/text.asp?2022/65/2/472/343197
Tuberculosis is one of the most common infections in India which is caused by Mycobacterium tuberculosis. Echinococcus is a cyclophyllid cestode and Aspergillus is a saprophytic fungus, both species are well known to cause infections in immunocompromised patients. Primarily these three infections are mainly present as lung lesions individually. Coexistence of these three infections in a single patient is very rare. Long-standing cavities in the lung can easily be colonized by saprophytic fungi like aspergillus. Deterioration of patient immunity is the major cause of these consequences.
A 53-year-old woman who was a defaulter case of pulmonary tuberculosis presented with hemoptysis since 10 days. Her blood pressure was 130/80 mmHg, SpO2 – 97% at room air. Total leucocyte count – 5,400/mm3, hemoglobin – 10.9 g/dl were within normal limits. Serology for HBsAg was negative and HIV was nonreactive. The bronchoalveolar lavage fluid was positive for acid-fast bacilli. Echinococcus serum IgG level was 58.75 unit (negative <9). First CECT scan of chest showed thick wall cavitary lesion with central and peripheral air foci in the superior segment of left lower lobe likely post-consolidation and a well-defined oval shape low attenuation lesion with mild peripheral enhancement was noted in the posterior basal segment of left lower lobe likely to be an abscess. She was advised Anti Tubercular Therapy for 6 months. During the course of treatment, hemoptysis resolved; however, she complained of persistent chest pain since few months. A repeat CECT chest done for the unresolving chest pain showed two well-defined heterogenous density lesions in posterior basal segment of left lower lobe with internal folded membranes & air foci suggestive of ruptured infected hydatid cyst [Figure 1]. Intraoperatively the cyst was identified, pericyst was incised and enucleated. The specimen was submitted for histopathological evaluation [Figure 2]. Histopathological examination revealed cyst wall composed of eosinophilic laminated chitinous layer of hydatid cyst. Inner wall lined by mixed inflammatory infiltrate comprising of lymphocytes, macrophages, and neutrophils with adherent eosinophilic granular material containing entrapped balls of septate fungal hyphae morphologically consistent with aspergillus species. Splendore–Hoeppli phenomenon was noted. The fungal hyphae are seen invading the chitinous layer [Figure 3] and [Figure 4]. Periodic acid Schiff and Gomori’s methenamine silver stain highlights fungal organisms.
|Figure 1: A well-defined oval shape low attenuation lesion with mild peripheral enhancement was noted in the posterior basal segment of left lower lobe measuring 5.7 × 3.7 cm|
|Figure 2: Grossly received multiple fragmented pearly white cystic tissue pieces largest measuring 6 × 4 cm with wall thickness of 0.2-0.4 cm, adherent brownish necrotic tissue also noted|
|Figure 3: Eosinophilic laminated chitinous layer of hydatid cyst with fungal infection, H and E stain, 10x × 10x|
|Figure 4: Inner wall is lined by mixed inflammatory infiltrate comprised of lymphocytes, macrophages and neutrophils with adherent eosinophilic granular material containing entrapped balls of septate fungal hyphae, H and E stain, 10x × 40x|
Throughout the centuries, tuberculosis has prevailed as a ubiquitous infectious disease that has evolved in India with myriad of presentations. Other coinfections with tuberculosis have been variably reported in literature to date. Hydatid disease and aspergillosis are two such coinfections, occurring individually in patients with TB, which have been seldom reported and studied. Aspergillosis in the lung commonly colonizes diseased cavities of tuberculosis, bronchiectasis, sarcoidosis, malignancies, or sometimes pulmonary infarcts., But the main concerning symptom was hemoptysis which is not so common in tuberculosis only but frequently seen in aspergillus infection due to angio-invasion. Hydatid disease, a zoonotic infection, the most common localization is liver (50–70% of all cases), followed by lungs (20–30%). The existence of either of the fungal or hydatid disease has been well documented in a fair number of cases to date. However, the co-existence of both infections was extremely rare.
Laldayal et al. reported an elderly woman with cavitary lesion in lung with BAL examination showing positivity for Mtb. Specific IgE against Aspergillus fumigatus was negative and indirect hemagglutination assay against E. granulosus was positive. In the present case, clinical suspicion of hydatid cyst was made radiologically. However, an additional surprise of coexisting fungal infection was encountered on histopathological examination of excised cavitary lesion of the lung. On the contrary, in the case discussed by Laldayal et al., no histopathological examination or surgical intervention of the case was done.
A case reported in Shimla by Patial et al. also states the presence of coinfection of tuberculosis and hydatid disease, with contact history of animals. However, we report a pulmonary infection with no animal contact history.
A review of cross-sectional studies by Hosseini et al. showed a higher Aspergillus fumigatus in the age group more than 40 years. A study done in Iran by Amiri et al. found that 12.3% (16/130) tuberculosis cases had secondary fungal infection. Page et al. studied 398 Ugandans with treated pulmonary TB. Those were underwent reassessment and Aspergillus-specific IgG measurement after 2 years showed 6.5% cases with residual cavitary lesions in lung with coexistent fungal infections. Our case was an active case of pulmonary tuberculosis with no clinical suspicion of aspergillosis infection.
In a retrospective analysis done by Koçer et al., found that out of 100 known cases of hydatid disease only 2 had colonization by Aspergillus species. These 2 cases were immunocompetent. Extensive colonization by Aspergillus in an unruptured hydatid cyst has been reported only once. However, in our case the cyst was ruptured.
As this co-infection is an incidental finding, a high degree of suspicion is needed to predict the superimposed co-infections. Early diagnosis and treatment is important to prevent potential complications stemming from infections by these two pathogens, such as massive hemoptysis. The true mechanisms for this co-infection will be revealed as the number of known cases accumulates, and continued studies will aid in choosing the best treatment options, like surgery to remove the cysts or anti-Aspergillus treatment.
Careful handling at the time of surgery is beneficial. The ruptured hydatid cysts are prone to spread the fungal organisms and thus requiring further treatment. The clinical presentation as hemoptysis gives a suspicion about angio-invasion by aspergillosis. Aspergillosis and echinococcosis share the same symptoms and crescent signs on chest CT, so it is difficult to diagnose both coexistent infection at the same time. Since radiological techniques have less sensitivity and specificity in diagnosing such secondary infections, the onus of diagnosis in such lies on the pathologist via histopathological evaluation. Due to the lack of improvement in tuberculosis symptoms following completion of antitubercular chemotherapy, identification of coinfections is necessary for early prevention from development to advanced fibrotic stage and avoid pulmonary disability. There is a paucity of literature about the effect of one infection on the other, the associated complications, and treatment. Unconventional clinical and radiological presentations in such coinfections pose a diagnostic and therapeutic challenge to the physician.
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K Verma Kartavya
Department of Pathology and Laboratory Medicine, Academic Block, Third Floor, All India Institute of Medical Sciences, Raipur (C.G.), Chhattisgarh – 492 099
Source of Support: None, Conflict of Interest: None