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Airway Obstruction in a Patient After Kidney Transplant

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 60s with a history of end-stage renal disease who had a kidney transplant 9 months previously presented with progressive cough, dyspnea, and hoarseness. Her history also included chronic gastroesophageal reflux disease and a 14-pack-year smoking history. She initially presented 3 months prior with upper respiratory symptoms, which continued to worsen despite oral antibiotic therapy. Her cough became productive with white, frothy phlegm that was accompanied by fever, wheezing, hoarseness, and fatigue. Her dyspnea worsened in the supine position.

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D. Aspergillosis

Pathology results from supraglottic biopsy revealed branching, fungal microorganisms among superficial fragments of squamous epithelium. Culture and bronchoalveolar lavage results confirmed the diagnosis of Aspergillosis laryngotracheobronchitis.

Aspergillus tracheobronchitis (ATB) is an unusual form of pulmonary aspergillosis that is seen in fewer than 10% of aspergillosis-related cases.1 Patients with neutropenia and/or who are immunocompromised are at particular risk for ATB.2 Patients usually present with dyspnea, cough, and wheezing. Diagnosis of this rare entity is often delayed because of its nonspecific clinical presentation and lack of radiographic findings at early stages.3 Radiologic findings may include thickening of airways, patchy infiltrates, or no findings at all.1 Definitive diagnosis requires visualization with laryngoscopy or bronchoscopy and both pathological and microbiological biopsies.4

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Article Information

Corresponding Author: David G. Lott, MD, Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054 (lott.david@mayo.edu).

Published Online: May 9, 2019. doi:10.1001/jamaoto.2019.0772

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Fernández-Ruiz  M, Silva  JT, San-Juan  R,  et al.  Aspergillus tracheobronchitis: report of 8 cases and review of the literature.  Medicine (Baltimore). 2012;91(5):261-273. doi:10.1097/MD.0b013e31826c2ccfPubMedGoogle ScholarCrossref
2.
Segal  BH.  Aspergillosis.  N Engl J Med. 2009;360(18):1870-1884. doi:10.1056/NEJMra0808853PubMedGoogle ScholarCrossref
3.
Tasci  S, Glasmacher  A, Lentini  S,  et al.  Pseudomembranous and obstructive Aspergillus tracheobronchitis—optimal diagnostic strategy and outcome.  Mycoses. 2006;49(1):37-42. doi:10.1111/j.1439-0507.2005.01180.xPubMedGoogle ScholarCrossref
4.
Patterson  TF, Thompson  GR  III, Denning  DW,  et al.  Practice guidelines for the diagnosis and management of Aspergillosis: 2016 update by the Infectious Diseases Society of America.  Clin Infect Dis. 2016;63(4):e1-e60. doi:10.1093/cid/ciw326PubMedGoogle ScholarCrossref
5.
Denning  DW.  Commentary: unusual manifestations of aspergillosis.  Thorax. 1995;50(7):812-813. doi:10.1136/thx.50.7.812PubMedGoogle ScholarCrossref
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