ABPA mimicking bronchogenic cancer J. M. F. Sa Ânchez-Alarcos*, R. Martõ Ânez-Cruz, L. Ortega, M. Calle, J. L. Rodrõ Âguez-Hermosa, J. L. A Â lvarez-Sala Key words: allergic bronchopulmonary aspergillosis; bronchial asthma; bronchoscopy; fungal hyphae; lung cancer; mucoid impaction. . WE report a case of bronchopulmonary aspergillosis (ABPA) that was exceptional because, ®rstly, ABPA was diagnosed in a patient without evidence of asthma, and, secondly, the endobronchial mass found at bronchoscopy led to a misdiagnosis of bronchogenic carcinoma. A 65-year-old man with a smoking history of 20 cigarettes a day from the age of 15 to 45 years had had persistent cough and some mucous expectoration for 5 months. A small in®ltrate in the right upper lobe was seen on the chest roentgenogram, and complete obstruction of the apical and posterior segmental bronchi of the right upper lobe by a whitish irregular mass was detected by ®beroptic bronchoscopy. Microscopic examination of biopsies revealed fragments covered by respiratory epithelium with squamous metaplasia; an in®ltration of lymphocytes, plasma cells, and neutrophils; edema; and focal necrosis. Ziehl-Neelsen and periodic acid-Schiff stains of biopsy samples were negative. A computed tomography (CT) scan of the chest disclosed a nodular mass in the right upper lobe with a peribronchovascular in®ltrate that spread to the hilum. With the diagnosis of bronchogenic carcinoma, a thoracotomy with atypical resection of the apical and posterior segments of the right upper lobe was performed. Bronchi ®lled with abundant mucoid material with areas of mixed in®ltrate that disrupted the bronchial wall were observed on micro- scopic examination of the surgical specimen, and a diagnosis of bronchiectasis with abscessed bronchopneumonia was made. One year after operation, the patient was readmitted because of persistent cough, expectoration, and systemic symptoms of illness. Laboratory studies were negative except for a serum IgE level of 2370 U/ml. The chest roentgenogram showed bilateral perihilar alveolar in®ltrates, but multiple transbronchial biopsies, and bacteriologic tests were unrevealing. Histopathologic review of the surgically excised lung tissue specimens revealed large bronchial dilations with the bronchial lumen ®lled with mucoid material and an in¯ammatory in®ltrate. In®ltrating cells were mostly eosinophils. Small bronchioles showed disrupted walls and were ®lled with necrotic cellular remnants and an intense mixed in¯ammatory in®ltrate, although without evidence of well-de®ned granulomas. Through the methenamine silver stain, septate hyphae of Aspergillus were clearly observed in the mucous plugs, and the diagnosis of ABPA was established. Precipitating antibodies and immediate skin reactivity to Aspergillus antigen were then observed. Treatment with oral prednisone resulted in a remarkable clinical response and resolution of the pulmonary in®ltrate. Cases of ABPA in nonasthmatic patients have been occasionally reported in the literature. In eight of the 19 cases of ABPA in nonasthmatic patients (1, 3±5), a bronchogenic carcinoma was initially suspected due to abnormalities in the chest roentgenogram (mostly atelectasis), but bronchoscopy revealed typical mucous plugs. By contrast, in our patient, the diagnosis of lung cancer was based on bronchoscopic ®ndings of an endobronchial mass of malignant appearance, rather than on roentgenographic characteristics. Moreover, in addition to immediate skin reactivity to Aspergillus antigen, precipitating antibodies, and markedly elevated IgE, lung biopsy specimens were available in which the histopathologic features of ABPA were identi®ed. The microscopic ®nding of mucoid impaction of bronchi in conjunction with noninvasive fungal hyphae is highly suggestive of ABPA (6). There is a previous description of such pathologic features in surgically excised lung tissue specimens (7). This study reports that operation was performed in ®ve cases because of preoperative suspicion of neoplastic bronchial obstruction, which was found on the chest roentgenogram or at the time of bronchoscopy. Although the endoscopic ®ndings are not described, this study (7) and the case reported here indicate that mucoid impaction of bronchi in ABPA may have the endoscopic appearance of bronchogenic carcinoma. Therefore, ABPA should be included in the differential diagnosis of bronchial obstruction of neoplastic aspect. Acknowledgment We thank Marta Pulido, MD, for editorial assistance. ALLERGY 2001: 56:80^90 . COPYRIGHT G MUNKSGAARD 2001 . ISSN 0105-4538 . ALL RIGHTS RESERVED . CONTRIBUTIONS TO THIS SECTION WILL NOT UNDERGO PEER REVIEW, BUT WILL BE REVIEWED BY THE ASSOCIATE EDITORS . Mucoid impaction of bronchi in a nonasthmatic patient. 80