What happened, in summary

This 71-year-old woman had a history of Stage IA lung adenocarcinoma treated with right upper lobectomy in November 2018. The tumor was staged T1bN0M0, and she did not receive chemotherapy or radiation after surgery. About 8 months later, she developed symptoms that suggested invasive fungal sinusitis and underwent endoscopic sinus surgery, but no specific organism was identified then. Roughly 1 year after the lung operation, she began having chest tightness, shortness of breath with exertion, sputum production, and a nighttime cough. Breathing tests showed obstructive ventilatory dysfunction, and inhaled corticosteroids with long-acting bronchodilator therapy gave only limited control. In March 2020, CT imaging showed patchy shadows in the right lower lobe. Antibiotics helped briefly, but symptoms returned and a later CT showed an enlarging, high-density cast-like lesion, raising concern for either cancer recurrence or fungal disease. Bloodwork showed elevated total IgE and mild eosinophilia, findings that supported an allergic airway process. Bronchoscopy found swollen airway lining and thick white mucus plugs. Bronchoalveolar lavage and brush testing identified Schizophyllum commune, and both specific IgE testing and skin testing showed a strong immune response to the fungus. She was diagnosed with allergic bronchopulmonary mycosis rather than recurrent lung cancer. Treatment with voriconazole plus inhaled corticosteroid/formoterol improved her chest tightness, shortness of breath, cough, eosinophil count, IgE level, and lung function. Her FEV1 rose from 1.52 L before treatment to 1.70 L after treatment, and the FEV1/FVC ratio improved from 0.65 to 0.74. After 3 months, CT showed near-complete absorption of the right lower-lobe lesion and no new lesions.