Aspergilloma

Gross appearance: This slice of lung shows an aspergilloma in the superior segment of the lower lobe. Note the fibrous wall and the parenchymal fibrosis that extends to the pleura, which is thickened.

Histologic changes: The wall of the aspergilloma shows a partially eroded lining of metaplastic squamous epithelium, overlying chronically inflamed granulation tissue and scar. Note the large vascular channels with little smooth muscle in their walls. These branches of the bronchial artery can be a source of bleeding.

Aspergilloma (syn: Fungus ball)

Introduction: Aspergillomas--saprophytic growths of fungus in a preformed cavity--occur in adults with lung disease caused by tuberculosis (up to 17% of such patients), sarcoidosis, bronchiectasis (cystic fibrosis [1]), lung abscess, neoplasms, or pneumocystis in AIDS [2,3]. They consist of intraluminal masses of hyphae, blood clot, and cellular debris. The cavity may be lined by epithelium that often includes foci of squamous metaplasia. When other fungi occupy the cavity, the non-committal term "fungus ball" is used.

Clinical features: Some aspergillomas are discovered incidentally on radiographs, but most patients present with hemoptysis or productive cough [3]. Dyspnea, fever, weight loss, or clubbing may be present [4]. Diagnosis, based on a chest radiograph, is confirmed by CT and by culture or histologic identification of aspergillus hyphae in sputum, lavage fluid, or transthoracic needle aspirates [5], or by serologic demonstration of aspergillus precipitins [3]. Most lesions are solitary and occur in the upper lobes [2]. A few are multiple or occur in other lobes [6]. Cavities average 3 to 5 cm in diameter. An air crescent lies above the fungus ball, which may move when the patient changes position. The wall and the adjacent pleura show variable thickening [2].

Differential diagnosis: Cavitating abscess or neoplasm, and a hematoma in a cavity are included in the radiographic differential diagnosis.

Therapeutic options are controversial. About 10% resolve spontaneously [7]. Others are not treated. Excision is advocated for severe hemoptysis in suitable candidates, but postoperative complications, including bronchopleural fistula and empyema occur [2,4,6]. Instillation of various antifungal agents (amphotericin B, N-acetylcysteine, and aminocaproic acid [8]; amphotericin B alone [1]; or iodides [9]) into the cavity sometimes controls bleeding. An associated invasive disease may occur, especially in AIDS patients [3]. There is a general consensus that systemic antifungal agents do not cure the disease although they can control associated invasive disease [2,4]. In a retrospective study of 85 patients, there was no difference in 5-year survival of patients with little or no hemoptysis treated medically or by surgical resection. In those with recurrent hemoptysis or a single major bleed, the 5-year survival was 41% for the medically treated and 84% for those undergoing surgical resection (p<0.02). Part of the difference may have been related to patient selection [6].

References

1. Ryan P, Stableforth D, Reynolds J, Muhdi K. Treatment of pulmonary aspergilloma in cystic fibrosis by percutaneous instillation of amphotericin B via indwelling catheter. Thorax 1995; 50:809-810.

2. Glimp R, Bayer A. Pulmonary aspergilloma. Diagnostic and therapeutic considerations. Arch Intern Med 1983; 143:303-308.

3. Addrizzo-Harris D, Harkin T, McGuinness G, Naidich D, Rom W. Pulmonary aspergilloma and AIDS. A comparison of HIV-infected and HIV-negative individuals. Chest 1997; 111:612-618.

4. Rafferty P, Biggs B-A, Crompton G, Grant I. What happens to patients with pulmonary aspergilloma? Analysis of 23 cases. Thorax 1983; 38:579-583.

5. Stanley M, Deike M, Knoedler J, Iber C. Pulmonary mycetomas in immunocompetent patients: diagnosis by fine-needle aspiration. Diagn Cytopathol 1992; 8:577-579.

6. Jewkes J, Kay P, Paneth M, Citron K. Pulmonary aspergilloma: analysis of prognosis in relation to haemoptysis and survey of treatment. Thorax 1983; 38:572-578.

7. Hammerman K, Christianson C, Huntington I, Hurst G, Zelman M, Tosh F. Spontaneous lysis of aspergillomata. Chest 1973; 64:697-699.

8. Shapiro M, Albelda S, Mayock R, McLean G. Severe hemoptysis associated with pulmonary aspergilloma. Percutaneous intracavitary treatment. Chest 1988; 94:1225-1231.

9. Rumbak M, Kohler G, Eastrige C, Winer-Muram H, Gavant M. Topical treatment of life threatening haemoptysis from aspergillomas. Thorax 1996; 51:253-255.

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