Aspergillus fumigatus-induced acute fibrinous and organizing pneumonia complicated by spontaneous subcutaneous and mediastinal emphysema: a case report and literature review.

BACKGROUND: Acute fibrinous and organizing pneumonia (AFOP) is a rare and distinct histopathological pattern of acute lung injury characterized by intra-alveolar fibrin deposition. It poses significant diagnostic and therapeutic challenges due to its heterogeneous etiologies and the lack of standardized clinical guidelines. CASE PRESENTATION AND METHODS: We report the clinical course of a 58-year-old male presenting with Aspergillus fumigatus-associated AFOP complicated by spontaneous subcutaneous and mediastinal emphysema. Diagnosis was confirmed via CT-guided percutaneous lung biopsy. Additionally, we conducted a systematic literature review of PubMed and EMBASE databases (January 2019 to July 2024) to analyze the clinical-radiological features, etiological spectrum, and treatment outcomes of 31 unique AFOP cases. RESULTS: The case patient presented with fever, chest pain, and dyspnea. Following confirmation of A. fumigatus-induced AFOP and management of secondary mediastinal emphysema via negative-pressure closed thoracic drainage, the patient showed a favorable response to combined corticosteroid and antifungal therapy. The literature review of 31 patients revealed a male predominance (17/31, 54.8%) with a mean age of 55 ± 15 years (range: 22-78). Fever was the most prevalent clinical presentation (23/31, 74.2%), followed by cough (19/31, 61.3%) and dyspnea (13/31, 41.9%). Chest computed tomography (CT) predominantly revealed consolidation (22/31, 71.0%) and ground-glass opacities (12/31, 38.7%). Identified etiologies were highly heterogeneous, including idiopathic forms, infections, hematologic malignancies, and autoimmune disorders. Glucocorticoid-based regimens achieved an overall treatment response rate exceeding 73%. CONCLUSION: AFOP is a multifaceted pulmonary disorder associated with non-specific symptoms and radiological features like consolidation and ground-glass opacities. Aspergillus infection can trigger AFOP, which may be rarely complicated by spontaneous mediastinal emphysema. Early histopathological confirmation and individualized immunomodulatory therapy are crucial for favorable clinical outcomes. LIMITATIONS: This study is limited by a small literature cohort size, a lack of multivariable analysis, and limited molecular epidemiological data.