Multiple fungus balls in rheumatoid arthritis–associated honeycomb lung

Excerpt

A 78-year-old woman presented to the respiratory disease department with exertional dyspnea. Three years previously, she was diagnosed with seropositive rheumatoid arthritis (RA) with concomitant usual interstitial pneumonia (UIP) in a different hospital and had been on a regimen of glucocorticoids and tacrolimus hydrate (Fig. 1a). Bilateral fine crackles were heard on chest auscultation. Chest computed tomography revealed bilateral honeycombing with basal predominance, progression of fibrosis in the left lower pulmonary lobe, and multiple recently developed nodules in the clustered cystic airspaces in the right lower pulmonary lobe (Fig. 1b). Although the sputum culture result was negative for mycosis, Aspergillus galactomannan antigen value was 3.5 (cutoff index, < 0.5). Therefore, chronic pulmonary aspergillosis with concomitant RA-associated interstitial pneumonia was diagnosed. Despite treatment with antifungal agents, including voriconazole and itraconazole, and reversal of tacrolimus, she died 20 months after clinical presentation due to progression of aspergillosis.

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