Aspergilloma
💡 Key Point: Aspergilloma (“fungal ball”) often forms in old TB cavities.
🚨 The major risk is massive haemoptysis → may require surgery or bronchial artery embolisation.
📖 About
- An aspergilloma is a clump of Aspergillus fumigatus colonising a pre-existing lung cavity.
- On imaging, it appears as a rounded intracavitary opacity with an air crescent/halo sign.
- The fungus does not invade surrounding tissue but may cause vascular erosion → haemoptysis.
🧬 Aetiology
- Develops when Aspergillus spores colonise cavities left by chronic lung disease.
- Most common cause: Post-tuberculosis cavitary lesions 🦠.
- Aspergillus fumigatus isolated in ~60% of patients with fibrotic cavities.
📌 Predisposing Conditions
- 🦠 Tuberculosis: Cavities from old or active TB.
- 🌿 Sarcoidosis: Chronic fibrosis with cavitation.
- 🎗️ Lung carcinoma: Tumour necrosis cavities.
- 🦠 Bacterial lung abscess/suppurative pneumonia: Post-infectious cavities.
- 🌫️ Fibrosing alveolitis / advanced ILD: Occasional cavitation.
- 🦴 Ankylosing spondylitis with apical fibrosis: Associated apical aspergillomas.
- 🌍 Histoplasmosis / granulomatous disease.
- 🌀 Bronchiectasis due to ABPA: Cavities colonised by fungus.
🩺 Clinical Features
- Many remain asymptomatic (incidental on CXR).
- 🚨 Haemoptysis: Most serious symptom; may be life-threatening due to erosion of bronchial vessels.
- Chronic cough ± sputum, recurrent minor haemoptysis.
- Less common: pleuritic chest pain, fever, weight loss.
- Apical aspergillomas may coexist with ankylosing spondylitis.
🔎 Investigations
- CXR: Rounded mass within cavity, with an air crescent.
- CT chest: Defines fungal ball and cavity anatomy.
- Sputum culture: May yield Aspergillus. Always exclude TB reactivation.
- Serology: Raised IgG to Aspergillus supports diagnosis.
💊 Management
- 👀 Observation: If asymptomatic and haemoptysis absent.
- 🔪 Surgery (lobectomy/resection): Indicated in severe/recurrent haemoptysis.
⚠️ High perioperative risk (bronchopleural fistula, empyema).
- 🩸 Bronchial artery embolisation: Life-saving temporising measure for massive haemoptysis.
- 💊 Antifungal therapy:
- Itraconazole: May reduce fungal load and haemoptysis episodes.
- Voriconazole: Alternative in refractory cases.
- 📍 Bronchoscopy: Diagnostic role; sometimes for clot/mucus clearance.
📈 Prognosis
- Asymptomatic lesions can remain stable for years.
- Risk of massive haemoptysis = main cause of mortality.
- Outcomes depend on underlying lung disease and surgical risk.
📚 References
3 Clinical Cases — Aspergilloma (“Fungal Ball”) 🍄🫁
- Case 1 — Post-tuberculosis cavity 🧫: A 54-year-old man treated for pulmonary TB 10 years ago presents with recurrent episodes of mild haemoptysis and chronic cough. CXR: cavitating lesion in the upper lobe with a rounded opacity and an air crescent sign. Teaching: Aspergillomas often colonise old TB cavities. Classic radiology shows a mobile intracavitary mass with surrounding air. Management depends on symptoms — observation if mild; surgery or embolisation if significant haemoptysis.
- Case 2 — COPD with old bullae 🚬: A 67-year-old man with severe COPD and bullous lung disease presents with weight loss, cough, and streaky haemoptysis. HRCT: thin-walled cavity in the right upper lobe containing a soft-tissue density with an air crescent. Teaching: Aspergillomas may form in bullae or cavities due to emphysema. The main risk is recurrent or massive haemoptysis. Treatment may include antifungals, bronchial artery embolisation, or surgical resection if operable.
- Case 3 — Sarcoidosis-related aspergilloma 🌫️: A 45-year-old woman with stage IV pulmonary sarcoidosis develops chronic productive cough and intermittent haemoptysis. CT chest: fibrotic upper lobe with a cavity containing a fungal ball. Teaching: Fibrotic lung disease (sarcoid, fibrosis) predisposes to aspergilloma formation. These patients often have poor lung reserve, so surgery is high risk. Management usually conservative with haemoptysis control; antifungals may be used in selected cases.
