Abstract
Introduction Patients with end-stage pulmonary sarcoidosis complicated by chronic infection are at high risk for recurrent pneumothoraces and massive hemoptysis. Structural lung distortion, aspergilloma formation, and severe pulmonary hypertension make management particularly challenging. This case illustrates catastrophic tension pneumothoraces and intrapulmonary hemorrhage in a patient with sarcoidosis and aspergilloma, despite aggressive surgical and medical intervention. Case Description A 58-year-old man with stage IV sarcoidosis, pulmonary hypertension, bronchiectasis, and chronic aspergillus mycetoma presented with worsening dyspnea. Past history included tonsillar carcinoma treated with chemotherapy and radiation. CT imaging revealed bilateral pneumothoraces: a left-sided pneumothorax and two right-sided pneumothoraces within one week, requiring serial chest tube placements. CT angiography showed a new left basilar pneumothorax, stable left apical cavity with fungal debris, dilated right pulmonary artery consistent with pulmonary hypertension, and no pulmonary embolism (Figure 1). Posaconazole therapy was initiated for aspergillosis. Persistent air leak despite tube upsizing prompted video-assisted thoracoscopic (VATS) partial decortication with mechanical and chemical pleurodesis. Despite adequate drainage and antimicrobial coverage, the patient developed hypoxemic and hypercapnic respiratory failure. Duplex ultrasound later demonstrated extensive bilateral deep vein thromboses, necessitating heparin infusion. Within 48 hours, he developed hemoptysis and active bleeding into the cavitary fungal lesion, resulting in septic and cardiogenic shock. Despite maximal support, the patient’s condition deteriorated, and he died from multisystem failure. Discussion This case exemplifies the lethal intersection of end-stage sarcoidosis, pulmonary hypertension, and chronic aspergillus infection. Structural destruction from fibrosis and cavitary disease predisposes to recurrent pneumothoraces and massive intrapulmonary bleeding, especially under anticoagulation. Management requires early recognition, immediate decompression of tension physiology, antifungal therapy, and definitive pleural intervention such as pleurodesis. However, in advanced disease, surgical stabilization may not overcome underlying parenchymal fragility and hemodynamic compromise. Multidisciplinary coordination among thoracic surgery, pulmonology, and critical care is essential, though mortality remains high. This case highlights the need for early transplant referral and anticipatory management of complications in patients with end-stage granulomatous lung disease complicated by fungal infection. This abstract is funded by: None