Chronic cavitary aspergillosis transformed from allergic bronchopulmonary aspergillosis (ABPA)

Longstanding asthma, ABPA with chronic cavitary pulmonary aspergillosis. The patient suffered a long history of severe steroid-dependent asthma with recurrent infective exacerbations culture positive for Aspergillus fumigatus and Pseudomonas aeruginosa. An Aspergillus precipitins test was positive with an elevated total IgE level. Despite initial treatment with oral itraconazole, chest radiograph deteriorated, showing cystic cavities in both apices and a computed tomography scan showing a right upper lobe mycetoma (fungal ball). She developed respiratory failure and was established on long-term oxygen therapy of 2 L/min via an oxygen concentrator at home and oxygen conserver when mobile. Systemic steroids, nebulizers, and long-term itraconazole did not prevent disease progression of ABPA to chronic cavitary aspergillosis. She was treated with voriconazole for >5 years with some benefit, although very slow deterioration requiring 4 L/min oxygen 24 hours a day.