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CASE REPORT Table of Contents  
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A rare case report of tracheobronchial aspergillosis with endobronchial aspergilloma in a patient clinically recovered from COVID-19

1 Department of Pulmonary Medicine, AIIMS, Patna, Bihar, India
2 Department of Radiodiagnosis, AIIMS, Patna, Bihar, India

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Date of Submission01-Aug-2021
Date of Decision23-Jan-2022
Date of Acceptance27-Jan-2022
Date of Web Publication26-May-2022


The novel coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has led to an increased incidence of fungal infections. However, pulmonary infections are rare. COVID-associated pulmonary aspergillosis has been reported; however, there is no prior report of tracheobronchial aspergillosis with endobronchial aspergilloma as per the authors' literature search. We report such a case of a 65-year-old male with radiology and biopsy-proven endobronchial aspergilloma upon a background of tracheobronchial and pulmonary aspergillosis after having recovered clinically from severe COVID-19 disease.

Keywords: Bronchoscopy, COVID-associated pulmonary aspergillosis, COVID-19, endobronchial aspergilloma, invasive pulmonary aspergillosis (IPA), SARS-CoV-2, tracheobronchial aspergillosis

How to cite this URL:
Rai DK, Kumar S. A rare case report of tracheobronchial aspergillosis with endobronchial aspergilloma in a patient clinically recovered from COVID-19. Indian J Pathol Microbiol [Epub ahead of print] [cited 2023 Feb 5]. Available from:

   Introduction Top

Patients with severe coronavirus disease (COVID-19), especially those in an intensive care unit (ICU), are particularly vulnerable to fungal infections, including aspergillosis and invasive candidiasis.[1],[2],[3] Such infections are being increasingly reported and have known association with high morbidity and mortality.[4],[5] Further, as fungal infections can be detected after the apparent recovery from COVID-19, awareness of such infections, with knowledge of various common and rare presentations, is essential to reduce management delays and prevent mortality.

   Case Report Top

A 65-year-old male, diabetic non-smoker, presented with dry cough and mild chest pain in the left side of the chest, which exacerbated on coughing. He had a history of severe COVID-19 a month back, for which he was hospitalized at another center and managed with non-invasive oxygen supplementation, parenteral steroids, and antibiotics. He had recovered from the acute disease in about 2 weeks and was able to maintain oxygen saturation at room air, but the cough had persisted, making him seek our advice. On examination, he had a heart rate of 96 beats per minute, a respiratory rate of 20 breaths per minute, a blood pressure of 106/81 mmHg, and an oxygen saturation of 96% at room air. On chest examination, air entry was reduced in the left infra-axillary area. A high-resolution computed tomography (HRCT) scan performed during the acute phase had shown bilateral peripheral and lower lobe predominant ground glass opacities [Figure 1]a, whereas a fresh scan revealed a thick-walled cavity in the left lower lobe with adjacent consolidation, pleural effusion, and bilateral ground glass and reticular opacities [Figure 1]b. His blood investigation revealed hemoglobin 10.7 gm%, total leukocyte count 9.13/microliter, neutrophil 57.7%, lymphocyte 36.3%, and eosinophil 4.1%. Sputum culture did not grow any pathogen. Video bronchoscopy was performed, which showed whitish mucoid secretion in the left main bronchus [Figure 2]a, [Figure 2]b, which was partially adhered to the airway wall. A reddish endobronchial mass lesion was found at the level of the left upper lobe bronchus from which a biopsy was taken [Figure 2]c. Microscopic potassium hydroxide (KOH) examination of a bronchial alveolar lavage (BAL) sample revealed septate hyphae with right-angled branching suggestive of aspergillus [Figure 3]a, and histopathological examination of the biopsy sample suggested an aspergilloma [Figure 3]b, [Figure 3]c. BAL fluid culture did not grow any bacteria; smear was negative for acid fast bacilli, and GeneXpert was negative for Mycobacterium tuberculosis. The BAL fluid Aspergillus galactomannan (GM) optical density index (ODI) was 3.57. Considering the clinic-radiological profile, KOH and biopsy findings, and the BAL GM ODI, a diagnosis of COVID-associated pulmonary aspergillosis (CAPA) with tracheobronchial aspergillosis and endobronchial aspergilloma was made. Oral voriconazole therapy was initiated, and review after 4 weeks was advised.
Figure 1: (a) Axial HRCT image during initial clinical presentation showing peripheral ground glass opacities in both lungs (b) Axial HRCT image at follow-up showing thick-walled irregular cavity at the left lower lobe with surrounding consolidation and few irregular linear opacities on both sides

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Figure 2: Video bronchoscopy image (a) and (b) showing irregular shiny white plaques adherent to the left main bronchus wall (c) a rounded polypoidal mass, which turned out to be aspergilloma

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Figure 3: (a) BAL fluid sample showing typical aspergillus fungi (b) and (c) histopathologic examination of biopsy from the tracheobronchial lesions showing fungal granuloma and aspergillus fungi

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   Discussion Top

Viral pneumonias have a known association with invasive pulmonary aspergillosis (IPA).[6] Similarly, the COVID-19 patients, especially those with acute respiratory distress syndrome (ARDS) and admitted to ICUs, can also be prone for IPA.[7] A new terminology has been given for the occurrence of IPA with COVID-19, known as CAPA. Although the case definition of CAPA is not well elucidated yet, there are several reports in the literature, and it has also been considered as an additional risk factor of mortality.[8],[9]

CAPA generally occurs in patients with a history of positive severe acute respiratory syndrome coronavirus 2 reverse transcriptase polymerase chain reaction (SARS-CoV-2 RT-PCR) anytime during 2 weeks between hospital admission and ICU admission or a positive RT-PCR within 72–96 hours after ICU admission. CAPA is categorized as possible, probable, and proven following various recommendations and presently is based on the present evidence and consensus.[6],[10],[11] CAPA can be pulmonary or tracheobronchial aspergillus infection. Proven CAPA cases should have histopathological or direct microscopic detection, or both, of fungal elements that are morphologically consistent with Aspergillus species, showing invasive growth into tissues with associated tissue damage, or (with or without) aspergillus recovered by culture or detected by microscopy in histologic studies or by PCR from the material that was obtained by a sterile aspiration or biopsy from a pulmonary site, showing an infectious disease. In our case, both the histopathological tissue and BAL fluid were positive for Aspergillus species. A BAL GM ODI of 3.57 also supported the diagnosis of a proven case of CAPA.

Bronchoscopic examination had shown lesions in trachea and bilateral bronchial tree secretions and plaques on the right side and a mass lesion on the left side, which turned out to be an aspergilloma [Figure 3]b. Typically, an aspergilloma is a fungal ball that develops in preformed thick-walled cavities. Classically, such lesions are detected incidentally on imaging or when they are evaluated for hemoptysis.[12] Tracheobronchial aspergillosis is a rare form of IPA, typically encountered in lung and heart-lung transplant patients at the bronchial anastomotic sites.[12]

The present case is unique in this regard as the patient did not undergo any airway intubation earlier and, except for his post-COVID-19 status, was presently healthy. He had no co-morbidity; however, he did receive steroids and antibiotics earlier, which might be a pre-disposing factor for the fungal infection. Another unique feature is the presence of both pulmonary and tracheobronchial disease.

   Conclusion Top

We report a rare case of concomitant tracheobronchial and invasive pulmonary aspergillosis in a previously healthy patient recently recovered from COVID-19. This case highlights the necessity for increased suspicion of fungal infections in such patients with persistent chest symptoms and the requirement for an appropriate battery of investigations including bronchoscopy, HRCT, and serum GM.

Author contribution

  1. Deependra Kumar Rai: Manuscript preparation
  2. Dr Subhash Kumar: Literature search.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Hoenigl M. Invasive fungal disease complicating coronavirus disease 2019: When it rains, It spores. Clin Infect Dis 2021;73:e1645-8.  Back to cited text no. 1
Garcia-Vidal C, Sanjuan G, Moreno-García E, Puerta-Alcalde P, Garcia-Pouton N, Chumbita M, et al. Incidence of co-infections and superinfections in hospitalized patients with COVID-19: A retrospective cohort study. Clin Microbiol Infect 2021;27:83-8.  Back to cited text no. 2
Lansbury L, Lim B, Baskaran V, Lim WS. Co-infections in people with COVID-19: A systematic review and meta-analysis. J Infect 2020;81:266-75.  Back to cited text no. 3
Gangneux JP, Bougnoux ME, Dannaoui E, Cornet M, Zahar JR. Invasive fungal diseases during COVID-19: We should be prepared. J Mycol Med 2020;30:100971. doi: 10.1016/j.mycmed. 2020.100971.  Back to cited text no. 4
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.  Back to cited text no. 5
Schauwvlieghe AFAD, Rijnders BJA, Philips N, Verwijs R, Vaderbeke L, Tienen CV, et al. Invasive aspergillosis in patients admitted to the intensive care unit with severe influenza: A retrospective cohort study. Lancet Respir Med 2018;6:782-92.  Back to cited text no. 6
Prattes J, Valentin T, Hoenigl M, Talakic E, Reisinger AC, Eller P. Invasive pulmonary aspergillosis complicating COVID-19 in the ICU - A case report. Med Mycol Case Rep 2021;31:2-5.  Back to cited text no. 7
Koehler P, Cornely OA, Böttiger BW, Dusse F, Eichenauer DA, Fuchs F, et al. COVID-19 associated pulmonary aspergillosis. Mycoses 2020;63:528-34.  Back to cited text no. 8
van Arkel ALE, Rijpstra TA, Belderbos HNA, van Wijngaarden P, Verweij PE, Bentvelsen RG. COVID-19-associated pulmonary aspergillosis. Am J Respir Crit Care Med 2020;202:132-5.  Back to cited text no. 9
Donnelly JP, Chen SC, Kauffman CA, Steinbach WJ, Baddley JW, Verweij PE, et al. Revision and update of the consensus definitions of invasive fungal disease from the European organization for research and treatment of cancer and the mycoses study group education and research consortium. Clin Infect Dis 2020;71:1367-76.  Back to cited text no. 10
Koehler P, Bassetti M, Chakrabarti A, Chen SCA, Colombo AL, Hoenigl M, et al. Defining and managing COVID-19-associated pulmonary aspergillosis: The 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. Lancet Infect Dis 2021;21:e149-62.  Back to cited text no. 11
Horan-Saullo JL, Alexander BD. Opportunistic Mycoses. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. Vol. 1. Elsevier Health Sciences. 2015 p. 675-76.  Back to cited text no. 12

Correspondence Address:
Deependra K Rai,
Department of Pulmonary Medicine, AIIMS, Patna - 801 507, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpm.ijpm_780_21


  [Figure 1], [Figure 2], [Figure 3]


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