CASE PRESENTATION

ASPERGILLOSIS
 BACKGROUND

‐ Name : Ny. T
‐ Gender : Perempuan
‐ Date of Birth : 11 Desember 1970
‐ Age : 46 tahun
‐ Religion : Islam
‐ Medical record : RSUS.00-63-43-XX
‐ Address : Jl.Pasir

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 ANAMNESIS

Alloanamnesis from patient’s family

Chief Complain:
Patient comes to hospital to get CT Scan thorax

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 HISTORY OF PRESENT ILLNESS
‐ Patient have to CT Scan thorax.
‐ 4 years ago patient had hemoptysis. Vomiting (-), sickness (-
).
‐ the color of hemoptysis is fresh blood and there’s a blood
clotting
‐ Volume of hemoptysis ½ tbsp ,
‐ SOB, chest pain, fever, night sweat, loss of appetite, and
loss of body weight (-)
 History of medication

‐ When she was young she used to consume an anti-

inflammation drugs such as dexamethasone,
without doctor prescription.

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 Family history

‐ Hypertension (-)
‐ Diabetes mellitus (-)
‐ TB (-)
‐ Fungal infection (-)

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 2.
Physical examination
 Clinical Manifestation / history taking

‐ General appereance : Vital sign :

‐ GCS : compos mentis ‐ Heart rate : 80x/menit,
(GCS E4M6V5) regular, symmetric.
‐ Respiratory rate :
18x/menit, regular
‐ Blood pressure : 100/80
‐ Temprature : 36,5
‐ SpO2 : 100%

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 PHYSICAL EXAMINATION
Sistem Deskripsi
Kulit Warna putih, lesi (-), perdarahan (-)
Kepala Normosefali, jejas (-)

Konjungtiva anemis (-/-)

Mata Sklera ikterik (-/-)
Pupil bulat, isokor, 2mm/2mm, RCL/RCTL (+/+)
THT Secret (-)
Leher Pembesaran KGB (-)
Dada Bentuk normal simetris, retraksi (-)

Inspeksi: perkembangan rongga dada saat statis dan dinamis simetris (+/+)
Palpasi: pengembangan dada simetris kanan dan kiri
Paru-paru
Perkusi: Tidak dilakukan
Auskultasi: vesikuler ¯/+, ronchi -/-, wheezing -/-, slem (stridor) -/-

Iktus kordis tidak terlihat, tidak teraba

Jantung Bunyi jantung S1 & S2 reguler
Murmur (-), gallop (-)

Inspeksi: bentuk datar, distensi (-), lesi (-), scar (-)

Auskultasi: BU (+)
Abdomen
Perkusi: timpani pada seluruh kuadran abdomen
Palpasi: NT (-), hepatomegali (-), splenomegali (-)
Punggung Massa (-), lesi (-), gibbus (-)
Ekstremitas Akral hangat, CRT <2 detik, edema (-/-)
 Laboratory value / full blood count
Full Blood Count V alue Unit éé/ êê Ref. Range
Hemoglobin 10.5 g/dL N 11.70 - 15.50
Hematocrit 33.8 % N 35.00 - 47.00
Erythrocyte (RBC) 4.80 10^6/μL N 3.80 - 5.20
White Blood Count 7.29 10^3/μL N 3.60 - 11.00
(WBC)
Differential Count 0/0/3/63/27/7 %%%%%% N N NNNN 0-1 1-3 2-6 50 - 70 25
• Basophil - 40 2-8
• Eosinophil
• Band Neutrophil
• Segment Neutrophil
Lymphocyte
• Monocyte
Platelet Count 348.00 10^3/μL N 150.00 - 440.00
ESR 65 mm/hours éé 0 - 20
MCV, MCH, MCHC • 81.30 26.00 34.00 fL NNN 80.00 - 100.00 26.00 -
MCV pg g/dL 34.00 32.00 - 36.00
• MCH
• MCHC
Ur 18
Cr 0,63
eGFR 106.8
 Acid fast bacilli & fungal culture

AFB DIRECT SMEAR (SEPT 2018)

Specimen : sputum
Procedure : ZN stain
Result :
Leukosit <100/lpf
Epithel : <10/lpf
Acid fast bacillus not found

Fungal culture : (+) aspergillus fumigatus

 Radiology examination

Consolidation inhomogen on
upper lobe dextra covering
superior mediastinum dextra with
infiltrate DD/aspergilloma , TB

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 CT SCAN THORAX WITH CONTRAST

‐ Thick-walled cavity with crescent water in it is accompanied by

ground glass opacity around it in the 1,2,3 right lung segment
measuring 8,3x5,23x7,59 cm and multiple reversed halo sign
and fibrosis in the 3.6 segment of the right lung with ground
glass opacity around it. .
‐ Pleural thickening of segment 6 of the right lung
‐ Centrilobular emphysema in the 10th segment of the right lung,
fibrosis in the 10th segment of the right lung
‐ Calcification in segment 3 of the left lung, removal of mild pleural
segment 6 of the left lung
‐ Lymphadenopathy multiple upper, lower, bilateral paratracheal,
subcarina, aortic, peribronchial diameter +/- 0.38-1cm.
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 RESUME
Patients came to the General Hospital on October 17, 2018 for a non-contrast Thoracic
CT-Scan plan. Previously patients had complaints of coughing up blood four years ago.
Coughing up blood is not preceded by nausea or vomiting. Fresh red coughing blood
sometimes blood clots. Coughing up as much as ½ tablespoon of blood that is lost. On
physical examination vital signs are within normal limits and vesicular sounds are
decreased in the upper right lung field.
On examination of the plain thorax showing the inhomogene connection in the upper
right lung field covering the right superior mediastinum with the surrounding infiltrate.
Non-contrast thoracic CT scan found a thick-walled cavity with crescent water inside it
with ground glass opacity around it in the 1,2,3 right lung segment measuring
8,3x5,23x7,59 cm and multiple reversed halo sign and fibrosis in segment 3, 6 right lung
with ground glass opacity around it.
 Working diagnosis & medication

Aspergillosis ‐ Itraconazole 2x100 mg

caps P.O
‐ Codeine 3x10 mg P.O
‐ Tranexamic acid
3x500 mg P.O

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 “
Case analytic

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 Causes hemoptysis

46-year-old female patient came to plan

a Thorax contrast CT Scan before the
patient had a complaint of coughing up
blood for four years. It is known that
hemoptysis can be triggered by several
things, namely

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‐ Complete examination : decrease in
hemoglobin and an increase in ESR which
showed an inflammatory reaction and
coughing up blood which decreases Hb in the
blood.
‐ Furthermore, the patient had an AP chest x-
ray examination showing the presence of
inhomogene intercourse in the field above the
right lung covering the right superior
mediastinum with the surrounding infiltrate.
Inhomogenous connections can be found with
conditions of pulmonary TB, pneumonia and
aspergilloma.
However, if it is reconnected to clinical and investigative
support for pulmonary TB patients, it can be excluded
because the results of negative 3x smear sputum and
clinical pneumonia are not found in these patients, so this
patient can be suspected of aspergillosis.

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 Patient has a ct scan thorax contrast

Thick-walled cavity with crescent water

in it is accompanied by ground glass
opacity around it in the 1,2,3 right lung
segment measuring 8,3x5,23x7,59 cm
and multiple reversed halo sign and
fibrosis in the 3.6 segment of the right
lung with ground glass opacity around it.
--> invasive aspergillosis

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 Management

‐ The main therapy for invasive aspergillosis is

the administration of variconazole, with the
initial administration of antifungal in patients
with suspected IPA.
‐ IDSA recommends giving anti-fungal drugs for
6-12 weeks, depending on the severity and
duration of immunisuppresion, the place of
predilection and evidence that the progression
of the disease is reduced. However, this
patient was given itraconazole as his choice
‐ In addition, this patient is given tranexamic
acid in order to reduce symptoms of coughing
up blood. Codeine to reduce the frequency of
coughing.5
 Thank you

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