Multimodal interventional bronchoscopy for chronic pulmonary Aspergillus infection with post-tubercular bronchial occlusion: a case report.

Chronic pulmonary aspergillosis (CPA) is an increasingly recognized complication of both active and treated pulmonary tuberculosis (PTB). Optimal treatment for CPA in PTB patients has not been established. Here, we report a 36-years-old female with a history of childhood pulmonary tuberculosis presenting with persistent low-grade fever after COVID-19 infection. Imaging showed right upper lobe consolidation and bronchial occlusion. Laboratory investigations revealed positive bronchoalveolar lavage fluid (BALF) and serum galactomannan, and microbiological analyses including targeted Next-Generation Sequencing (tNGS) identified Aspergillus terreus, consistent with a diagnosis of CPA. Systemic voriconazole was ineffective due to subtherapeutic drug levels and was complicated by visual adverse effects. Multimodal interventional bronchoscopy was performed, including Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA), electrosurgical incision, balloon dilation, cryotherapy, and local antifungal perfusion. Clinical and radiological improvement was achieved, with resolution of fever, lesion absorption on CT, and negative microbiological and GM results. This case indicates that customized multimodal interventional bronchoscopy is a feasible and effective strategy for post-tubercular chronic pulmonary aspergillosis with bronchial occlusion when systemic antifungals are not optimal.