Definition

• An Aspergilloma is defined as a conglomeration of intertwined fungal hyphae admixed with mucous and cellular debris within a cavity or an ectatic bronchus.
• 25- 55 % of cases have an underlying Pulmonary tuberculosis.
• 11% of cases of pulmonary TB had radiographic evidence of aspergilloma in a prospective study, which progressed to 17% over 3 years.
• The other common underlying condition is sarcoidosis.
• Bronchiectasis due to any of the following causes is another underlying condition
  • cystic fibrosis,
  • chronic fungal cavities,
  • bronchogenic cysts,
  • radiation fibrosis and
  • cavitating carcinoma.
• Although Aspergillus species form the vast majority of these fungal balls, candida, norcardia and streptomyces species have also been identified within these lesions.

• Rounded soft tissue density mass within a spherical cavity, usually in the upper lobe.
• Mass is separated from the wall of the cavity by an air space of variable size. Fluid level is rarely seen.
• Cavities are usually thin walled and thickening of the wall of the cavity has been described as the earliest sign of aspergillus colonisation antedating the detection of the fungal ball.
• Calcification can occur within the fungal ball, as small scattered nodules on the periphery or extensively within the fungal ball.

• Ovoid or round soft tissue density intra-cavitary mass which moves to the dependant portion when the patient is turned from supine to prone position.
• Areas of increased attenuation represent calcification within it.
• In cases where the air crescent is not identified, fine irregular fungal strands may be identified at the periphery.

Diagnosis

• positive precipitin test to fungal antigen
• elevated level of Aspergillus specific IgE levels.
• Post resection, the IgE levels decrease, but rarely become negative.
• CT guided biopsy / Fine needle aspiration cytology can be performed, histology revealing fungal hyphae or fungal culture growing the aspergillus species.

Prognosis

• Spontaneous lysis is seen in 5-10% of cases.
• Some disappear when bacterial infection develops within the cavity.
• Rarely, massive haemoptysis can cause death.
• Local pulmonary invasion or disseminated disease may occur.

Other disease processes due to aspergillus

• Extrinsic allergic alveolitis
• Loeffler like syndrome
• Allergic bronchopulmonary aspergillosis.

Treatment options

• Systemic antifungal therapy
• Excision of the cavitory fungal ball
• Intracavitoru CT guided instillation of Amphotericin.

Reference