CLINICAL PRESENTATION , DIAGNOSIS AND TREATMENT OF PULMONARY FUNGUS BALL RELATED TUBERCULOSIS

Pulmonary fungus ball is common complication from pulmonary tuberculosis with cavity, especially from sequele pulmonary tuberculosis. Etiologic agents not only Aspergilus sp but also Candida sp. Definitive treatment is surgical therapy. In special condition we can choose another treatment. We evaluated six pulmonary fungus ball patients with history of antituberculosis drugs, in several method of diagnosis from 2010 sampai 2013. We analyze the therapy and outcome from the patients. Hemoptysis presented in all patients and three of them got massive hemoptysis. All patients had specific appearance of pulmonary fungus ball radiologically. Fungus species confirmed in five patients: serologic examination (1), fungal culture (2), and histopathological examination (2). The species are Aspergilosis sp = 3, Candida parapsilosis = 1 and Candida sp = 1. Two of them got surgical therapy and there is no more complaint of hemoptysis. Those four who took anti fungal only, so three of them (75%) good responsive both clinically and radiologically. Preexisting cavity in pulmonary tuberculosis and former pulmonary tuberculosis, renounce the incident of pulmonary fungus ball which need lobectomy as definitive treatment. In condition where they can’t perform surgical treatment, antifungal can be alternative treatment and gave good outcome.


INTRODUCTION
Preexisting lung cavity that caused by variety underlying lung disease, could be colonized by sacrophytic fungi such as Aspergillus (most common), Candida, Nocardia, Sporothrix and Peniccilium resulted fungus ball.related with tuberculosis (60%).Conglomeration of necrotic debris within the lung cavity and saprophytic growth on the lung surface occurs after inhalation of spores into the moist, warm, dark, aerated and proteinrich environment of the lung.Accumulation of layers of fungus, cellular debris, fibrin and inflammatory cells from a mobile, compact mass that may fill the cavity.

1,3
The common clinical presentation is some combination of cough, expectoration, hemoptysis, chest pain, wheezing and night sweats.But the most common symptom is hemoptysis (50-90%), could be bloodtinged sputum or massive. 1,3,4Bleeding has been attributed to mechanical friction between the mobile fungus ball and the hypervascular cavity wall, to endotoxins liberated from the fungus ball, or to type III inflammatory reaction within the cavity wall. 2 The classical plain chest radiograph and thoraxic CT scanning features of a pulmonary fungus ball is characterized by the presence of a solid, round or oval mass with soft-tissue opacity within a lung cavity.Typically, the mass is separated from the wall of the cavity by an airspace of variable size and shape, resulting in the "air crescent" sign. 1,2,4The common sites of pulmonary fungus ball are the upper lobe and lower lobe superior segment. 5 The causes of pulmonary fungus ball can be detected by microscopic, culture, serologic, PCR examination and histopathological examination. 4The specimen can be from sputum, bronchoalveolar lavage (BAL), brush from bronchoscopy.The selection of method and sampling based on examiner and the available facility on the hospital.
Eventhough surgical resection is the definitive treatment for pulmonary fungus ball 7, the best treatment for patients who are ineligible for surgery remains unknown. 4Patients with recurrent hemoptysis or massive hemoptysis, surgery is performed with considering the complication of surgery which mainly depend on pulmonary function and general condition.
It is considered for embolization or anti fungal medication intracavitary if surgery cannot perform.Pulmonary resection is most common in the surgical treatment but has high morbidity and mortality. 7This serial case report is going to perform six patients with pulmonary fungus ball related Tuberculosis in term of diagnose methods, treatment and outcome.

CASE
We found six patients, 4 men and 2 women with range of age 35-61 years old.The main symptoms were hemoptysis and cough (Table 1).
Three patients suffered from massive hemoptysis and the rest were not suitable for massive criteria, but they got recurrent hemoptysis.The right upper lobe was the most common location of fungus ball (  3).From clinical symptom there is nomore hemoptysis or bloody sputum in 6-12 months.From radiology, the pulmonary fungus ball is dissapear (Table 4).

Tabel 1 . 1 Tabel 2 .
Present signs and symptoms of six patients with pulmonary fungus ball Location of pulmonary fungus ball of six patients with pulmonary fungus ball

8 Fluconazole
carcinoma.Fungal mix with cellular debris, fibrin and inflammatory cell formed a mass that called fungus ball.1 In this serial case we report six pulmonary fungus ball patients related to Tuberculosis, one in current tuberculosis and five as former tuberculosis.Tuberculosis has reported to be the most common underlying disease of pulmonary fungus ball (60%).It has been reported that the most common symptom associated pulmonary fungus ball is hemoptysis.1,3,4It is similar with our series.Three of our patients had massive and recurrent hemoptysis and the rest just recurrent hemoptysis.The cause of haemoptysis is neovascularization of the diseased segment from the internal mammary, intercostals and phrenic system of vessels.The pulmonary vascular system may also contribute to neovascularization.Other symptom that present in our series are chronic cough.The apical portion of upper lobe especially right upper lobe were the common sites of disease in this series, which seem to reflect an association with pulmonary tuberculosis.Plain chest radiography is usefull in demonstrating the presence of a mass within a cavity.The lesions have been more frequently found in the upper lobes of the lungs, reflecting the predisposition of tuberculosis to cavitate in these areas A typical radiologic finding of pulmonary fungus ball is a solid, round or oval mass with soft-tissue opacity within a lung cavity, manifesting an "air crescent sign" without significant enhancement. 1,2,4In our series, all patients had typical radiograph appearance both in plain chest x-ray and thoracix CT scan.Surgery has generally been considered to be mainstay of treatment for pulmonary fungus ball.The main indication for surgery is massive and recurrent hemoptysis.The major mode of therapy for pulmonary fungus ball has been surgical resection of the cavity and removal the fungus ball.Lobectomy is the most commonly employed procedure, although segmentectomy is sometimes adequate and pneumonectomy is occasionally required.Antifungal therapy is rarely considered as main treatment of pulmonary fungus ball.The main indication for medical therapy has been that the patient is not fit for surgical intervention or there is concern about concomitant tissue invation by the fungus.As in our series, only two patients underwent lobectomy and the patients had no longer hemoptysis.Four others couldn't perform surgical treatment because of the patient had poor lung function (1) and rejection (3).For those, we gave antifungal as the treatment; fluconazole and itraconazole.Itraconazole has been used with some reduction of size of the fungus ball and has been shown being well penetrate in to the lung cavity.is extensively used for the prevention and treatment of superficial and invasive Candida infections. 9In our series, two patients with itraconazole for six month showed no more hemoptysis and decreasing in volume of fungus ball that caused by from candida parapsilosis and aspergilosis radiologically.One patient respon with fluconazole for six months.Only one patient showed poor respon from pulmonary tuberculosis and former pulmonary tuberculosis, renounce the incident of pulmonary fungus ball which need lobectomy as definitive treatment.In condition where they can't perform surgical treatment, antifungal can be alternative treatment and gave good outcome.Antifungal may create the opportunity for patient that ineligible to perform surgical treatment.Nevertheless, larger number of patients and multicentre site still required to get more reasonable recommendation.

Table 2
).All radiologic findings both in plain chest radiograph and thoracic Ct scanning, there was typical appearance such crecentic sign.Fungal species confirmed by serologic examination in one patient, fungal culture in two patients and histopathology examination in two patients.Two patients undergo thoracic surgery (lobectomy).Others who ineligible for surgery, got antinfungal (Triazol): itrakonazol (2), flukonazol (1), flukonazol and itrakonazol (1).Antifungal given six month each, and three patients gave good response (Table

Table 3 .
The diagnosis, etiology, therapy and outcome of six patients with pulmonary fungus ball * More than 50% ** Empty cavity appearance

Table 4b .
Radiologic findings pre and post therapy of six patients with pulmonary fungus ball