Chronic pulmonary aspergillosis (CPA) may mimic pulmonary tuberculosis (PTB). The two diseases are clinically indistinguishable and may result in CPA misdiagnosed as PTB or vice versa. Although, PTB is largely recognised as a differential diagnosis of CPA and often ruled out prior to CPA diagnosis, the converse is uncommon. The aim of this study was to determine the proportion of CPA cases among patients being assessed for PTB. A cross-sectional survey was conducted among consecutive patients referred for GeneXpert Mycobacterium tuberculosis (MTB) test for the diagnosis of PTB at the Korle-Bu Teaching Hospital, Accra, Ghana. Patients’ demographics, clinical and socioeconomic details were obtained using a structured questionnaire. Blood was collected for Aspergillus and HIV serology, and sputum samples obtained for Aspergillus culture. Chest radiograph was obtained, and computed tomography (CT) scan was also done for patients with positive Aspergillus serology or cavitation. CPA was defined using an algorithm developed by the Global Action for Fungal Infections (GAFFI) international expert panel. One hundred and fifty-four patients were included in the analysis, of whom 134 (87%) did not have a prior PTB diagnosis. There were 41 (26.6%) GeneXpert positive cases. CPA prevalence was 9.7% overall, but 50% in patients with a prior history of PTB and 3.7% in those without previous PTB. Although CPA is rarely considered as a differential diagnosis of PTB in Ghana, our findings show that CPA may affect half of patients being assessed for PTB relapse. Efforts to diagnose CPA should be prioritised in this patient group.

Pulmonary tuberculosis (PTB) remains a major public health challenge in low- and middle-income countries. PTB may leave residual cavitation following treatment in some patients, allowing saprophytic colonization by Aspergillus species, resulting in a slow, progressive lung condition known as chronic pulmonary aspergillosis (CPA). PTB is the commonest underlying condition in CPA, mainly post-treatment. CPA is likely to be misdiagnosed as PTB reactivation due to clinical and radiological similarities. Ghana has a significant PTB burden, but only one case of clinically and radiologically diagnosed CPA has been reported, and epidemiological studies are also lacking. The definitive diagnosis of CPA comprises symptomatology, imaging findings and mycological evidence. Mycological evidence is critical to rule out other differential diagnoses, including non-Aspergillus pulmonary fungal infections and has implications for treatment choice. Herein, we present a case of mycologically-confirmed CPA in a previously treated PTB patient.

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objectives Chronic pulmonary aspergillosis (CPA) is a common complication of tuberculosis. Previous studies on CPA in TB had involved general TB patients with a majority not bacteriologically proven. Although, ruling out evidence of TB is critical in diagnostic algorithms for CPA, in rare cases, CPA may occur in patients with active TB. This prospective longitudinal study aimed to determine the incidence of CPA at three timepoints in a cohort of bacteriologically confirmed TB patients placed on anti-TB therapy in Ghana. Methods Consecutive patients in whom MTB was detected by molecular analysis (GeneXpert MTB) and subsequently placed on anti-TB treatment were enrolled. They were screened for CPA at baseline or the time of TB diagnosis (0-1 week), end of treatment (6-7 months), and post-treatment (12-13 months). Screening involved assessment of signs and symptoms, quality of life (QoL) using St. George's Respiratory Questionnaire, imaging investigations (chest radiograph and/or CT scan), and mycology testing (LDBio Aspergillus IgG & IgM ICT and culture). CPA cases were defined based on a diagnostic algorithm developed for resource-constrained settings. During follow-up timepoints, CT scan was done when Aspergillus serology changed from negative to positive. GeneXpert MTB or acid-fast bacillus (AFB) smear results were obtained from laboratory records during follow-up timepoints. Results A total of 46 patients were enrolled at baseline, of whom 34 (74%) were resurveyed at the end of treatment. Only 13 patients have been screened post-treatment so far. There were 6 (13%) relapse cases. At baseline, Aspergillus serology was positive in 4 (8.7%) patients and later increased to 6 (17.6%) and now 3 (23.1%) at the end and post-treatment respectively. Specifically, 4 (8.7%), 2 (6.9%), and 1 (10.0%) patient(s) met the criteria for CPA at baseline, end of treatment, and post-treatment respectively. All four cases of CPA described at baseline occurred in relapse patients. Among these patients, the initial MTB load determined by GeneXpert MTB was either trace or very low and follow-up AFB smear and/or GeneXpert MTB were negative between 2 to 3 months. Among relapse patients, average years since the primary episode of TB was four in those with CPA versus nine in those without CPA. Persistent cough and hemoptysis were the common symptoms of CPA. All CPA patients had cavitation, irregular intraluminal lining of cavity, and all but one had pleural thickening and/or paracavitary fibrosis. Two CPA patients at baseline have been rescreened post-treatment, one still has features of CPA and one had died. Also, the two CPA patients at the end of treatment continue to have CPA features when rescreened. Quality of life score improved significantly at the end of treatment for TB without CPA (51.4-3.8) while for those with putative CPA co-infection the improvement was less (53.8-25.7). Conclusion CPA should be considered in patients with suspected TB relapse, a very low or trace GeneXpert MTB, and positive Aspergillus serology. These patients had a less satisfactory symptom improvement after TB treatment. Aspergillus serology testing at the beginning of TB relapse therapy may provide prognostic information.