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Pulmonary fungus ball in a patient with sarcoidosis.

CLINICAL PRESENTATION A 46-year-old female with history of fibrocystic pulmonary sarcoidosis presented with increased cough and hemoptysis for 2 days. She denied a history of fever, chills, malaise, night sweats or weight loss. Her vital signs were stable with an unremarkable physical examination. Chest x-ray (Figure 1A) and computed tomography scan of chest (Figures 1B and 1C) showed a well-demarcated cavitary mass in the right upper lobe with air crescent sign (arrows). Sputum samples were negative for acid-fast bacilli. Bronchial washes showed fungal elements on direct examination. She underwent right upper lobectomy, and on pathological examination, mass was composed of septate hyphae, branching at 45° angles, morphologically consistent with Aspergillus species. However, fungal culture from the surgical specimen and bronchial washings grew Pseudallescheria boydii (Figure 1D). Pulmonary fungus balls or mycetomas usually result from saprophytic colonization of pre-existing cavities by hyphae-producing fungi. Development of fungus balls is frequent in pulmonary cavitary sarcoidosis, with Aspergillus fumigatus being the most common causative fungus. Pseudallescheria boydii is usually associated with cutaneous mycetomas or “Madura foot.” It is the sexual form of fungus, Scedosporium apiospermum. Morphologically, P. boydii has septate hyphae with single terminal conidia, which branch at 45° angles and may be confused with Aspergillus. This case emphasizes the similarity of clinical and histological features of Aspergillus and Pseudallescheria infections. Differentiation of Pseudallescheria from Aspergillus is important because of its resistance to amphotericin-B and susceptibility to azole drugs.