A NEWLY published case report describes an exceptionally rare presentation of allergic bronchopulmonary aspergillosis (ABPA): pyopneumothorax, a condition not typically associated with the disease and one that can lead to delayed diagnosis in high-burden tuberculosis settings.
The case involved a 23-year-old woman with poorly controlled asthma who arrived with worsening breathlessness, chest pain and a large left-sided pyo-pneumothorax. Imaging revealed complete obstruction of the left main bronchus by a dense mucus plug and contralateral bronchiectasis, findings suggestive of a chronic allergic airway process rather than simple infection.
Her laboratory profile supported this diagnosis: total serum IgE was markedly elevated (over 6,300 IU/mL), with high levels of Aspergillus fumigatus-specific IgE and IgG. The constellation of features fulfilled modified ISHAM criteria for ABPA.
Pleural Disease Expands Clinical Spectrum of ABPA
ABPA is classically characterised by allergic inflammation of the airways, mucus impaction and central bronchiectasis; pleural involvement is considered very uncommon. Reported complications include pleural effusion, empyema, hydropneumothorax and the exceptionally rare pyopneumothorax described here.
Mechanisms proposed in the literature include intense immune-mediated pleural inflammation, superadded bacterial infection and complications arising from long-standing fibrotic airway disease.
The patient improved significantly with systemic corticosteroids and itraconazole, the standard combined immunosuppressive–antifungal approach. Her air leak resolved, and radiology showed marked improvement, leaving only mild pleural thickening as a sequela.
Importance of Early Recognition in TB-Endemic Regions
The authors stress that ABPA is frequently misdiagnosed as tuberculosis in low- and middle-income countries due to overlapping symptoms and radiological findings. Such delays risk progression to advanced airway destruction and pleural complications. For clinicians, the message is clear: asthmatics presenting with pleural disease, markedly elevated IgE and mucus plugging should be evaluated for ABPA, even when tuberculosis remains common.
Reference
Saini JK et al. Allergic Bronchopulmonary Aspergillosis Presenting as Pyopneumothorax. Ann Afr Med. 2025;DOI:10.4103/aam.aam_452_25.
