Semi-invasive Pulmonary Aspergillosis superimposed on untreated, longstanding Sarcoidosis.

Semi-invasive Aspergillosis is a type of pulmonary Aspergillosis that is seen in patients who are moderately immunocompromised, i.e., patients with underlying chronic lung disease like COPD who are on steroids.

A 44 year old African American female with chronic dyspnea and dry cough for two years, presented with worsening dyspnea, productive cough, subjective fever and more than 10% weight loss, since last three months. Three months prior to presentation, she was diagnosed with Sarcoidosis based on clinical and radiological findings. She had not received any steroid or immunosuppressive therapy.

On Physical examination, she was found to have low grade fever, mild hypoxia, and occasional crackles in bilateral lung fields. Lab data: WBC 14,700/cmm with 88% neutrophils, Chest X ray showed bilateral perihilar lymphadenopathy and chronic bullous disease of upper lobes with new upper lobe parenchymal infiltrates.

She was placed on respiratory isolation and was started on empiric antibiotics for community acquired pneumonia. Pulmonary was consulted for cystic sarcoidosis and for the evaluation of new infiltrates. AFB smears and HIV antibodies were negative. BAL showed multinucleated giant cells and asperillus fumigatus. She was started on voriconazole for semi-invasive pulmonary aspergillosis. She was subsequently discharged with partial resolution of symptoms.

Semi-invasive aspergillosis, also known as chronic necrotizing aspergillosis progresses over months to years usually affecting upper lobes. It is known to be exclusively seen in patients with chronic lung disease who are immunocompromised due to the use of steroids. Our case raises the question of whether chronic lung disease alone in an otherwise immunocompetent host is a risk factor for the development of semi-invasive aspergillosis.

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