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?
Lupus pernio - violeceous rash affecting the nose, cheeks, ears.
Chest: (B) crackles, more on the left
Arthritic changes - hands
What labs to order?
CBCD, CMP, CXR, PPD?
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
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