Massive hemoptysis due to pulmonary artery pseudoaneurysm in invasive aspergillosis in a patient with interstitial lung disease and suspected Aspergillioma: A case report

Background

Invasive pulmonary aspergillosis (IPA) is a serious complication, particularly in patients with existing structural lung disease like interstitial lung disease (ILD). Angioinvasive IPA can lead to pulmonary artery pseudoaneurysm (PAP), which is a rare but life-threatening source of massive hemoptysis.

Case presentation

We present the case of a 78-year-old white American male with ILD (potentially from Agent Orange exposure) and chronic hypoxic respiratory failure, dependent on home oxygen, who presented with recurrent, massive hemoptysis. Computed Tomography Angiography (CTA) showed a 1.5 cm PAP in the right upper lobe cavity. Despite no classical causative immunosuppression, a diagnosis of pulmonary aspergillosis was supported by bronchoalveolar lavage (BAL) culture and galactomannan testing. Although invasive disease was suspected, the possibility of an aspergilloma with a semi-invasive component could not be excluded due to lack of prior imaging. Urgent coil embolization was performed to control the hemorrhage, followed by antifungal treatment with voriconazole.

Conclusion

This case underscores the need for early suspicion of pulmonary aspergillosis in ILD patients, utilizing BAL and CTA for diagnosis, and combining endovascular embolization with antifungals. Given the absence of prior imaging and underlying fibrotic lung disease, distinguishing invasive disease from semi-invasive or chronic forms can be challenging.