# A Case of Pulmonary MALToma Camouflaged Within Invasive Pulmonary Aspergillosis

## TL;DR

A rare case of MALT lymphoma was discovered alongside invasive aspergillosis in a patient with chronic lung disease, highlighting the need for surgical evaluation in recurring haemoptysis.

## Contribution

First reported case of MALToma associated with invasive pulmonary aspergillosis.

## Key findings

- MALT lymphoma was identified in a lung resection specimen alongside proven invasive aspergillosis.
- Chronic inflammation from aspergillosis may contribute to the development of MALToma.
- Surgical resection revealed an unexpected malignancy despite initial conservative treatment.

## Abstract

A 59-year-old non-smoking male, with a known case of COPD (chronic obstructive pulmonary disease), treated pulmonary tuberculosis with Category 1 antitubercular drugs (six-month regimen) and was admitted with repeated bouts of moderate haemoptysis (~60 mL/day) for three days. The patient had a history of self-limiting occasional mild haemoptysis (~20 mL) over three years. An HRCT chest revealed a left upper lobe fibro-cavitary lesion with an intracavitary mass (air crescent sign), adjacent pleural thickening and fibrosis. Bronchoalveolar lavage (BAL) was positive for galactomannan and negative for Mycobacterium tuberculosis GeneXpert®. With the above clinical factors, host factors, and microbiological factors, the case was diagnosed as ‘probable’ invasive pulmonary aspergillosis and was treated with voriconazole. However, given relapsing haemoptysis despite adequate antifungal treatment, a left upper lobectomy was done. The resected left upper lobe specimen culture demonstrated Aspergillus fumigatus with histopathology confirming hyphae invading lung tissues confirming ‘proven’ invasive aspergillosis. Resected tissue also showed florid lymphoid tissue hyperplasia with Immunohistochemistry confirming the presence of a peculiar malignancy; MALT lymphoma/MALToma in the resected lobe. The association of a rare malignancy such as MALToma with invasive pulmonary aspergilloma (IPA) has been identified and reported for the first time. This could be because of a chronic inflammatory reaction elicited by the Aspergillus antigen. Long-standing fibro-cavitary disease and aspergillosis are partners in crime, augmenting the damages inflicted by one another. In such a scenario, early surgical intervention may be warranted if haemoptysis is moderate to severe or relapsing, following conservative medical management. Surgical resection may lead to the identification of unexpected diseases as in our case.