CRA9 SUCCESSFUL MANAGEMENT OF ASPERGILLOMA USING ISAVUCONZAOLE IN A VORICONAZOLE INTOLERANT PATIENT

Ad Rian Chong¹, Khai Lip Ng¹, Nur Husna Mohd Aminudin¹, Kasuma Mohamed Nordin¹
1 Division of Respiratory Medicine, Department of Internal Medicine, Melaka Hospital, Melaka, Malaysia

Introduction
Aspergillomas, or fungus balls, are a non-invasive form of pulmonary aspergillosis occurring within pre-existing pulmonary cavities, often resulting from prior infections such as tuberculosis. They are composed of Aspergillus hyphae, cellular debris, and mucus. Symptomatic cases can present with chronic cough, dyspnea, or life-threatening hemoptysis, requiring timely, individualized treatment. While surgical resection remains the standard of care for symptomatic aspergillomas, not all patients are candidates due to comorbidities or procedural risks. Antifungal therapy, particularly with triazoles like voriconazole, is used in nonsurgical cases but may be limited by intolerance.

Case Report
We present the case of a 76-year-old male with a history of pulmonary tuberculosis and colorectal cancer, who developed hemoptysis secondary to a large aspergilloma in the left upper lobe. Imaging and bronchoalveolar lavage confirmed Aspergillus fumigatus infection. Voriconazole was initially effective but discontinued due to hepatotoxicity. The patient declined surgical resection and bronchial artery embolization due to concerns about risk and recovery. Oral isavuconazole was initiated with careful monitoring. Over six months, the patient experienced resolution of symptoms and a marked reduction in aspergilloma size on follow-up imaging.

Discussion and Conclusion
This case highlights the therapeutic potential of isavuconazole in managing aspergilloma in patients not candidates for surgery or intolerant to conventional antifungals. Isavuconazole, a broad-spectrum triazole with a more favorable safety profile than voriconazole, demonstrated clinical efficacy and tolerability. Given limited data on isavuconazole use in non-invasive aspergillosis, this case contributes to emerging evidence supporting its role in complex scenarios.
Further studies are needed to establish standardized guidelines for isavuconazole use in aspergilloma, particularly regarding optimal dosing and treatment duration in non-surgical patients.