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.