Post-tuberculosis Aspergilloma in Undiagnosed Tetralogy of Fallot

Tetralogy of Fallot (TOF) is the most common congenital heart disease (CHD) with an incidence of four in every 1000 live births in Pakistan. Classically, these children present with central cyanosis in early life; however, milder defects may remain asymptomatic for months or even years. We report a malnourished and anemic teenage male, who was admitted with shortness of breath, hemoptysis, fever, palpitations, and weight loss. On examination, vitals were stable, except for oxygen saturation, which was 84% on pulse-oximeter. Bilateral basal coarse crepitations were present on respiratory examination with a markedly reduced air entry in the right upper zone. A 2-3/6 systolic ejection murmur was appreciated on cardiac examination. The chest X-ray was consistent with a collapsed right upper lobe with fibrosis. Echocardiography was consistent with findings of TOF. Based on sputum for acid-fast bacilli (AFB smear) and GeneXpert (Cepheid Inc., Sunnyvale, California, US) Mycobacterium tuberculosis/resistance to rifampin (MTB/RIF), the patient was diagnosed with multi-drug resistant pulmonary tuberculosis (MDR-PTB). However, when the patient didn't improve with anti-tuberculous therapy, a computed tomography (CT) scan chest was done, which raised a suspicion of aspergilloma. The culture and cytology of bronchoalveolar lavage (BAL) were done, which confirmed pulmonary aspergilloma. Undiagnosed congenital heart diseases are rare in adults. Pulmonary TB is rarely reported in right-to-left shunts; however, clinicians should maintain a suspicion of this correlation.