A 46-year-old female with history of fibrocystic pulmonary sarcoidosis presented with increased cough and hemoptysis for 2 days. She denied a history of fever, chills, malaise, night sweats or weight loss. Her vital signs were stable with an unremarkable physical examination. Chest x-ray (Figure 1A) and computed tomography scan of chest (Figures IB and 1C) showed a well-demarcated cavitary mass in the right upper lobe with air crescent sign (arrows). Sputum samples were negative for acid-fast bacilli. Bronchial washes showed fungal elements on direct examination. She underwent right upper lobectomy, and on pathological examination, mass was composed of septate hyphae, branching at 45° angles, morphologically consistent with Aspergillus species. However, fungal culture from the surgical specimen and bronchial washings grew Pseudallescheria boydii (Figure ID). Pulmonary fungus balls or mycetomas usually result from saprophytic colonization of pre-existing cavities by hyphae-producing fungi. Development of fungus balls is frequent in pulmonary cavitary sarcoidosis, with Aspergillus fumigatus being the most common causative fungus.
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