Mucus plugs in peripheral bronchi: An unusual initial manifestation of allergic bronchopulmonary aspergillosis.

Although allergic bronchopulmonary aspergillosis can be associated with mucus plugs in the central bronchi, this association in the peripheral bronchi remains unclear. A 78-year-old woman presented with mucus plugs in both the peripheral and the central bronchi in the right lung, which evolved into consolidation with high-attenuation mucus after one month.

CASE PRESENTATION

A 78‐year‐old woman without smoking history presented with paroxysmal nocturnal wheezing and coughing. Chest imaging revealed small mucus plugs in the peripheral and central bronchi in the right lung (Figures 1A and 2A–D). After one‐month treatment with inhaled corticosteroids and long‐acting β‐agonists, her chest imaging findings worsened (Figures 1B and 2E–H). Laboratory test results revealed elevated levels of eosinophils (1850/μL), total immunoglobulin E (IgE; 2000 IU/mL), and Aspergillus‐specific IgE (Index, 26.73; normal cutoff index <0.27). Bronchoscopy revealed mucus plugs (Figure 3), and Aspergillus terreus was detected in bronchial lavage fluid, leading to the diagnosis of allergic bronchopulmonary aspergillosis (ABPA).

FIGURE 1

(A) Chest radiograph at initial visit showing small reticular opacities in the right middle zone. (B) Chest radiograph after 1 month showing worsened shadows in the right middle zone with developing consolidation.

FIGURE 2

(A–D) Chest computed tomography at initial visit showing mucus plugs in the peripheral bronchi in the right upper lobe (right B3, yellow arrowheads) and in the central bronchi in the right middle lobe (right B4, blue arrowheads), with partial atelectasis of the right middle lobe. (E–H) Chest computed tomography after 1 month showing consolidation with high‐attenuation mucus (red arrowheads)—a typical finding in allergic bronchopulmonary aspergillosis. Images A‐B and E‐F show the lung window, and images C‐D and G‐H show the plain mediastinal window

FIGURE 3

Bronchoscopic image showing mucus plugs in the right B4 bronchi

DISCUSSION AND CONCLUSION

The central and peripheral bronchi are located in the inner two‐thirds and outer one‐third of the lung, respectively. ABPA is characterized by the presence of central bronchiectasis and mucus plugs in the central bronchi on computed tomography. High‐attenuation mucus (HAM) is a specific radiographic finding of ABPA, with high‐diagnostic utility. This case illustrates that HAM can result from mucus plugs in the peripheral and central bronchi. In patients with asthma symptoms, physicians should consider the possibility of ABPA even if mucus plugs are found in the peripheral bronchi rather than in the central bronchi.

AUTHOR CONTRIBUTIONS

NH wrote the initial draft of the manuscript. AO was responsible for manuscript drafting and image modification. Both authors were involved in the treatment, critically revised the manuscript, and approved the final version.

FUNDING INFORMATION

This research was not supported by any specific grant from any funding agency in the public, commercial, or non‐profit sectors. Therefore, no funding body was involved in the study design; collection, analysis, and interpretation of the data; the writing of the manuscript; or the decision to submit the manuscript for publication.

CONFLICT OF INTEREST

None declared.

CONSENT

Written informed consent to publish this report was obtained from the patient prior to the submission process.