Ruptured Pulmonary Aspergilloma complicating into pyopneumothorax and bronchopleural fistula: A case report and review of literature

Introduction: Pyopneumothorax secondary to ruptured pulmonary aspergilloma is a rare but life-threatening complication of invasive pulmonary aspergillosis (IPA), particularly in patients without classical immunosuppression. In tuberculosis-endemic regions, post-tubercular cavities often serve as a nidus for Aspergillus colonization. However, due to overlapping clinical and radiological features with bacterial pneumonia or tuberculosis reactivation, IPA frequently remains underdiagnosed or is recognized late in its course. Case Presentation: A 62-year-old female with poorly controlled diabetes mellitus presented with acute respiratory distress and diabetic ketoacidosis. Chest imaging revealed a right-sided cavitary lesion with hydropneumothorax and underlying lung collapse. Intercostal drainage yielded purulent material, confirming pyopneumothorax. Despite initiation of broad-spectrum antibiotics and liposomal amphotericin B, the patient developed progressive hypoxemia and multiorgan dysfunction. Pleural fluid microscopy and elevated serum galactomannan established the diagnosis of Aspergillus fumigatus infection. Surgical intervention was deferred due to hemodynamic instability, and the patient unfortunately succumbed to her illness. Conclusions This case highlights a fulminant presentation of IPA complicated by pyopneumothorax in a non-classically immunosuppressed host. Review of similar reported cases demonstrates that aspergillus-associated pneumothorax and pyopneumothorax can occur across diverse immune states, often with poor outcomes related to delayed diagnosis. Early clinical suspicion, rapid fungal diagnostics, and timely initiation of antifungal therapy are critical to improving survival in patients with pre-existing pulmonary cavities presenting with acute respiratory compromise.