John Williams* Robert Lim Paul Tambyah Department of Infectious Diseases, National University Hospital of Singapore, 5 Lower Kent Ridge Road, Singapore 119074, Singapore *Corresponding author E-mail address: johnwilliams@doctors.net.uk (J. Williams) Corresponding Editor: William Cameron, Ottawa, Canada 5 January 2007 doi:10.1016/j.ijid.2007.01.007 Invasive Aspergillus fumigatus associated with liver and bone involvement in a patient with AIDS A 39-year-old male who had emigrated from Malawi to the UK presented to his general practitioner with an eight-week history of an intermittent non-productive cough. He had no hemoptysis or constitutional symptoms and was a non- smoker. He reported having been hospitalized for two months in Malawi for pulmonary Mycobacterium tuberculosis infec- tion (PTB) eighteen years previously. He was referred to the hospital outpatient clinic for further evaluation. Examination findings included decreased air entry at the left apex of the lung. A chest radiograph (CXR) showed left apical opacification and cavitation with associated volume loss (Figure 1). Sputum analysis for bacteria and acid-fast bacilli (AFB) were negative on special staining and culture. These findings were interpreted as representing previously treated PTB infection. The patient consented to HIV testing and was found to be HIV-1 antibody positive with a CD4 count of 21 Â 10 6 cells/l (2%) and HIV viral load of 233 000 copies/ ml. Co-infection with hepatitis B was confirmed by serology: HBsAg positive and HBeAg positive. Co-trimoxazole was started for Pneumocystis prophylaxis. Four weeks later he re-presented to hospital with a one- week history of severe frontal headache and general malaise, but no fevers, photophobia or nuchal rigidity. Clinical exam- ination was unremarkable except for the previously noted findings in the left lung field. A serum cryptococcal latex agglutination test (CrAg) was positive at a titer of 1:20. Lumbar puncture evaluation revealed an opening pressure of 18 cmH 2 O and microscopy confirmed the presence of Cryptococcus on India ink staining, a white cell count (WCC) of 2550 cells (95% mononuclear cells, 5% polymorphs) and fewer than five red blood cells. Cerebrospinal fluid (CSF) protein was 1266 mg/l (normal range 250—450 mg/l). The CSF glucose:plasma glucose ratio was 1:2. CSF CrAg was positive at a titer of 1:40. The patient was commenced on intravenous amphotericin B and flucytosine. Cryptococcus neoformans was cultured from the CSF. Abnormal results were also obtained for: hemoglobin (Hb) 7.9 g/dl (normal range 13.0—16.5 g/dl); mean cell volume (MCV) 75.5 fl (nor- mal range 79—96.0 fl); WCC 3.95 Â 10 9 cells/l (normal range 4.00—11.0 Â 10 9 cells/l); and lymphocytes 0.85 Â 10 9 cells/l (normal range 1.30—4.00 Â 10 9 cells/l). Neutrophils were 2.60 Â 10 9 cells/l (normal range 2.50—7.50 Â 10 9 cells/l). During treatment for cryptococcal meningitis, the patient complained of a productive cough of yellow sputum and pleuritic chest pain. A repeat CXR revealed cavitation in the apex of the left lung, unchanged from the investigations of four weeks previously. A fibreoptic bronchoscopy was normal and staining and cultures of bronchoalveolar lavage (BAL) fluid were negative for bacteria, Pneumocystis jirovecii (Pneumocystis pneumonia, PCP) and mycobacteria. Six further sputum samples were negative for bacteria and mycobacteria on stain and culture. A course of oral co- amoxiclav was prescribed for a presumed bacterial chest infection, which resulted in an improvement in his respira- tory symptoms. Prior to discharge the patient was converted to oral fluconazole 400mg daily. Two weeks following dis- charge he was clinically well and commenced on anti-retro- viral therapy consisting of zidovudine, lamivudine and efavirenz. Five months after diagnosis of cryptococcal meningitis the patient presented with a productive cough and pleuritic chest pain localized to the left apex. He denied any hemop- tysis. On examination he was afebrile and decreased air entry was again noted in the left upper lobe. Investigations showed a WCC 3.72 Â 10 9 cells/l, Hb 9.3 g/dl, MCV 87.9 fl, platelets 573 Â 10 9 /l (normal range 150—450 Â 10 9 /l), neutrophils 1.98 Â 10 9 cells/l, and lymphocytes 0.65 Â 10 9 cells/l. C- Reactive protein (CRP) was elevated at 192.1 mg/l (normal 550 Letters to the Editor Figure 1 Apical cavitation of the left lung.