A 72-year-old male patient complained of recurrent hemoptysis and dyspnea, and a chest X-ray and CT scan (Fig. 1) demonstrated the existence of a fungus ball (longest diameter: 28 mm) in a pulmonary cavity exhibiting idiopathic pulmonary fibrosis (IPF)-induced traction bronchiectasis. Although an examination of the patient’s sputum was inconclusive, he exhibited a high 1-3-beta-D-glucan

level (53.8 pg/mL) and an Aspergillus buy AZD2281 galactomannan antigen index of 2.2, which were suggestive of pulmonary aspergilloma. Voriconazole (VRCZ) was systemically administered for two months, before itraconazole (ITCZ) was systemically administered for a further month; however, this did not have any effect on the patient’s symptoms or the size of his aspergilloma. Since surgical treatment was not possible

due to the patient’s poor respiratory function, topical treatment R428 manufacturer was adopted. Fiberoptic bronchoscopy (FOB) was performed, and a yellow fungus ball was observed in the cavity connecting to the right B2bi-beta (Fig. 2(A)), a biopsy examination of which detected Aspergillus fumigatus. Since the fungus ball was visible during the FOB, L-AMB was transbronchially administered directly into the aspergilloma using a TBAC needle. One hundred mg/body (2.5 mg/kg) were administered during each treatment, which was equivalent to the dose that would have been administered during systemic therapy. The L-AMB was dissolved in distilled water at a concentration of 10 mg/mL and was administered through a TBAC needle (Fig. 2(B)) at a dose of 0.5 mL per instillation, with each instillation site being different from the previous sites in order to ensure the diffuse and appropriate permeation of L-AMB into the fungus ball. After the procedure, the patient was asked to adopt a right-sided posture for 1 h. The procedure was conducted once a week in the outpatient department for four weeks, and after its safety had been confirmed the L-AMB dose was increased to 200 mg/body, and the procedure was conducted a further three times. By the sixth round of Mannose-binding protein-associated serine protease treatment, the fungus ball had diminished in size and turned brown (Fig. 2(C)), and the breakage

of the aspergilloma into several parts was observed due to an increase in the internal pressure of the aspergilloma caused by the direct administration of L-AMB (Fig. 2(D)). Surprisingly, during the subsequent treatment period the aspergilloma fragments re-assembled into a single structured fungus ball. At three months after the seventh treatment round, the diameter of the aspergilloma had decreased to 14 mm (Fig. 3(A, B)). Then, the L-AMB dose was reduced to its initial level due to the shrinkage of the fungus ball, and two further rounds of treatment were performed. In the end, the aspergilloma disappeared at two months after the ninth round of treatment; i.e., seven and a half months after the start of treatment (Fig. 3(C, D)).