CASE 9103 Published on 28.03.2011

Bilateral aspergillomas

Section

Chest imaging

Case Type

Clinical Cases

Authors

Matos H, Patrício H, Catarino R, Dionísio A
Centro Hospitalar de Coimbra

Patient

48 years, male

Categories
Area of Interest Thorax, Lung ; Imaging Technique Conventional radiography, CT-High Resolution
Clinical History
A 48-year-old male patient with history of long exposure to dusts (especially plaster) and previous pulmonary tuberculosis (TB) presented with dyspnea on exertion, cough and hemorrhagic sputum. Smoking habit was not reported.
Physical examination revealed decreased intensity of vesicular breathing in right side and diffuse crackles at pulmonary auscultation.
Imaging Findings
Chest radiograph demonstrated two cavitary lesions presenting with the "air-crescent sign" in medial and upper zones of the lungs, bilaterally (Fig. 1).

In high resolution CT (HRCT) of the chest, diffuse fibrotic changes with areas of disruption of normal lung anatomy were present, associated with cavitations, most likely secondary to the previous TB infection. More specifically there were two thick-walled lung cavities containing radiodense "material". One of them presented with the classic "sponge like" appearance (Fig. 2), which changed position in prone HRCT (Fig. 3). The findings were consistent with the presence of fungus balls within the preexisted cavities.

The imaging findings are typical of multiple aspergillomas and the patient presented Aspergillus spp. in the sputum samples.
Discussion
Aspergillus infection is caused by fungi of the genus Aspergillus, abundant in soil and water. Several species exist, however, the most common are Aspergillus fumigatus and Aspergillus flavus [1, 2].

The spectrum of diseases in lungs range from aspergilloma to angio-invasive or airway-invasive aspergillosis, depending on immune system or concomitant diseases of the host [1, 2].

Aspergilloma (also known as mycetoma or fungus ball) is a collection of hyphae of fungus, almost with the morphology of a ball, also accumulating cellular debris [2], which usually colonizes already existing cavities, generally as a result of previous pulmonary diseases, such as sarcoidosis or pulmonary tuberculosis [1, 2]. This colonization usually begins as a nodular thickening of the cavity, formed by the conglomeration of hyphae. When not supportable within the inner wall, the fungus ball falls in the cavity, mixing with cellular debris and having a “sponge like” appearance due to presence of air pockets within the lesion. As there is no attachment to the wall of the cavity, the aspergilloma changes its position with the mobility of the patient.

Aspergillomas are more common in middle-aged patients, being asymptomatic and discovered accidentally. However, sometimes aspergillomas can be found following an episode of haemoptysis [1-3], which is a relatively frequent presentation. The cause of hemoptysis is not completely understood [1]. Our patient had a follow-up examination because of the history of tuberculosis, but nevertheless he presented hemorrhagic sputum as well.

The other types of Aspergillus infection allergic bronchopulmonary aspergillosis, semi-invasive aspergillosis, airway-invasive aspergillosis and angioinvasive aspergillosis [2].

Radiologic appearance of aspergilloma is very characteristic, especially on CT examination, which is virtually pathognomonic. Sputum cultures or the presence of precipitating antibodies can also be found, but neither is specific [1].
On chest radiograph there is a rounded opacity within a preexisting cavity, most commonly located in the upper lung lobes. As the opacity does not fill the cavity completely, the “air crescent” sign is seen [1-3].
On CT this sign can be well seen, with the presence of the fungus ball inside of a thickened wall cavity, usually with a “sponge like” appearance, and its mobility can be confirmed by changing the patient into prone position [1-3].

Differential diagnosis includeS necrotising pneumonia (invasive aspergillosis), echinococcal cyst or bronchogenic carcinoma.

A minority of aspergillomas can resolve spontaneously [2]. In cases of severe haemoptysis surgical resection is indicated [2].
Differential Diagnosis List
Bilateral aspergillomas
Necrotising pneumonia (invasive aspergillosis)
Echinococcal cyst
Bronchogenic carcinoma
Final Diagnosis
Bilateral aspergillomas
Case information
URL: https://www.eurorad.org/case/9103
DOI: 10.1594/EURORAD/CASE.9103
ISSN: 1563-4086