Sarcoidosis Patient with Hemoptysis due to Aspergillosis

Dr. Zouwayhed presents the case

45 yo AAF is admitted to the hospital with CC: cough productive of purulent sputum with streaks of blood for 3 days. She also c/o fever and chills. RoS is positive for weight loss of 30 lbs over 6 months.

Sarcoidosis for 13 years (first presented with cough and SOB), arthritis, lupus pernio, asthma, HTN

She was treated with 3 doses of Remicade for suspected RA 4 months ago. Her symptoms started 1 month after the Remicade treatment was stopped.

What do you think is going on?

Physical exam:
Lupus pernio - violeceous rash affecting the nose, cheeks, ears.
Chest: (B) crackles, more on the left
Arthritic changes - hands

What labs to order?

CXR shows (B) fibrotic changes, a faint LUL structure

How would you treat this patient?
Pneumonia protocol - Cefotaxime and Azithromycin

Would you order anything else?
A further review of patient's history revealed that she was treated with V-fend in the past for suspected aspergillosis. ID was consulted.

CT of the chest showed a mass in the LUL highly suspicious for a fungus ball - aspergilloma.

CT chest shows a fungus ball in LUL; enlarged spleen

What happened?
Sputum culture grew Aspergillus. V-fend PO was started and a cardiothoracic surgeon was consulted for aspergilloma excision.

The patient's symptoms improved and she was discharged home with a one week follow-up with her doctor.

What did we learn from this case?
Take a focused history, e.g. "Similar complaints in the past? What helped then? What medications?"
Think about rarer causes of hemoptysis as well as the most common ones.
There is a known association between Remicade and invasive Aspergillosis.
Suspect active TB or fungal infection in all patients who are taking or have taken Remicade.

Cutaneous Sarcoidosis: A Dermatologic Masquerader - AFP 4/02
Sarcoidosis: A Primary Care Review - AFP 1/98
Diagnosing Night Sweats - AFP 3/03
Invasive Pulmonary Aspergillosis Associated with Infliximab Therapy - NEJM 5/01

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