Stage IV lung adenocarcinoma with Aspergillus-associated empyema: disease control after chemotherapy and antifungal therapy

What happened, in summary

This male patient was hospitalized in May 2023 with 7 days of fever and cough that did not improve after cefuroxime and azithromycin. He had a 20-pack-year smoking history. Chest CT showed cavitary changes in the right lower lung, right pleural effusion, and mediastinal lymphadenopathy. Initial pleural drainage showed an exudative effusion and reactive fibrosis without tumor cells. Bronchoscopy then found an exophytic lesion obstructing the right middle-lobe bronchus, and biopsy showed epithelial malignancy consistent with lung adenocarcinoma. Bronchoalveolar lavage culture grew Aspergillus fumigatus. Next-generation sequencing identified a pathogenic NF1 mutation, but selumetinib was not used because of cost. Full staging classified the lung cancer as AJCC 8th cT4N3M1a, Stage IV. Treatment had to address both cancer and severe infection. Antifungal and anti-infective therapy included voriconazole, then itraconazole, nebulized amphotericin B, piperacillin-tazobactam, meropenem, micafungin, methylprednisolone, cefoperazone-sulbactam, and later moxifloxacin/meropenem/micafungin when the pleural effusion evolved into purulent empyema. Cancer treatment began with pemetrexed 0.8 g plus cisplatin 30 mg on day 1. He completed 6 cycles every 21 days, then stopped chemotherapy because of compliance issues. He also completed 6 months of oral itraconazole. During 12 months of follow-up, no recurrence was observed, and his course showed overall disease stability after combined chemotherapy and anti-infective management. He still had Stage IV lung adenocarcinoma, but the infection, empyema, and cancer course were brought under control during follow-up. No targeted therapy was given because selumetinib was not accepted, so treatment relied on cytotoxic chemotherapy and infection control with careful outpatient surveillance.