2 CASE HISTORY
A 77-year-old Japanese man was referred to our hospital at X-12 months for further examination of abnormal chest shadows. He had never smoked and had a 30-year history of consuming 40 g/day of alcohol. He had been diagnosed as having hepatocellular carcinoma associated with alcoholic steatohepatitis at age 65 and underwent partial hepatectomy (S1/S6/S8), a total of four transcatheter arterial embolizations, and chemotherapy with sorafenib for postoperative recurrence. And he had only received best supportive care for hepatocellular carcinoma from X-12 months. Chest X-ray and computed tomography (CT) showed an infiltrative shadow in the right upper lobe with cavities and bronchiectasis (Figure 1A), so we performed sputum examinations and identified Mycobacterium avium in different multi-day specimens, thus resulting in a diagnosis of M. avium pulmonary disease. We started combination therapy of clarithromycin 600 mg/day and ethambutol 750 mg/day without rifampicin due to concerns about his hepatic functional reserve. Chest images showed apparent improvement in the infiltrative shadow at X-3 months, but cavitary lesions and bronchiectasis remained in the same area (Figure 1B). At X-21 days, he was prescribed 2 mg/day of dexamethasone by his palliative care physician to address his low appetite due to the progression of his hepatocellular carcinoma with cirrhosis (Figure 1C). At X-10 days, he suddenly noticed swelling of his neck and visited the physician again, where a chest X-ray revealed pneumomediastinum and subcutaneous emphysema with no apparent change in the lung field (Figure 1D). His dyspnea gradually worsened in the days that followed, and he was admitted to our hospital.
On physical examination, chest auscultation was normal and subcutaneous emphysema was palpable in the anterior neck. Chest CT revealed extensive infiltration from just below the pleura to the middle layer in the left lower lobe, and ground-glass opacities were recognized at the margins (Figure 1E). Laboratory examination revealed significantly high serum levels of C-reactive protein (10.2 mg/dL), β-D-glucan (804 pg/mL) and aspergillus antigen (> 5.0) (Table 1). He also had alcoholic liver cirrhosis with a moderate Child-Turcotte-Pugh score and elevated α-fetoprotein and protein induced by vitamin K absence, presumably due to the progressive hepatocellular carcinoma.
We suspected bacterial or fungal pneumonia because of the acute onset and the lack of worsening of the right upper lobe lesion due to M. avium pulmonary disease, and we started treatment with meropenem 3 g/day and micafungin 150 mg/day. However, his respiratory and hepatic failure progressed rapidly with the expansion of the infiltrative shadow and new cavitary nodules (Figure 1F), and by the third day of hospitalization, he was unable to communicate due to hepatic encephalopathy and required the use of mask oxygen at 8 L/min. The rapid deterioration of his general condition made bronchoscopic evaluation difficult, and he died of multiple organ failure on the sixth day of hospitalization. The results of sputum tests submitted during hospitalization were received postmortem, and no bacteria, acid-fast bacilli, or malignant cells were detected, but Aspergillus terreus was identified in cultures of several specimens, which ultimately led to the diagnosis of IPA.