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Pulmonary Aspergilloma: Bronchoscopic Appearance

Qureshi, Mohammed A MD; Nair, Vijayachandran S. MD

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Aspergillus species can colonize preexisting pulmonary cavities, resulting in an intracavitary fungus ball (aspergilloma). Diagnosis of aspergilloma is made on the basis of characteristic radiographic findings, positive serum precipitins against Aspergillus species, and culture of the organism from sputum. Bronchoscopy is performed to determine the site of bleeding in persistent hemoptysis associated with aspergilloma or to rule out an alternate cause such as bronchogenic carcinoma. Direct visualization of the fungus ball during bronchoscopy is rare. We report the direct visualization of an aspergilloma during bronchoscopy.

From the Carl T. Hayden Veterans Affairs Medical Center, Phoenix, Arizona, U.S.A. (Drs. Qurishi and Nair).

Reprints: Vijayachandran S. Nair, MD, Section of Pulmonary/Critical Care, Carl T. Hayden Veterans Affairs Medical Center, 650 E. Indian School Road, Phoenix, AZ 85012-1892, U.S.A.; (e-mail: vijayachandran.nair2@med.va.gov).

Pulmonary aspergilloma (fungus ball) results from saprophytic colonization by Aspergillus species of preexisting pulmonary cavities from a variety of causes, such as tuberculosis, 1 histoplasmosis, 2 sarcoidosis, 3 and pulmonary blastomycosis. 4 We report the bronchoscopic appearance of an aspergilloma in a patient with preexisting pulmonary cavity from Myobacterium avium/ intracellulare infection.

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CASE REPORT

A 75-year-old man was admitted to the hospital for progressive dyspnea and recurrent hemoptysis of 30 to 40 mL per day for the previous 3 to 4 days. He reported right-sided pleuritic chest pain but did not have any fever or diaphoresis. He had lost 15 lbs. in the previous month despite having a good appetite.

He was a 30 pack-year cigarette smoker and had chronic obstructive pulmonary disease. He also had a history of alcohol dependence. In 1998, chest radiography revealed bilateral upper lobe fibrocavitary infiltrates and sputum cultures yielded M. avium/intracellulare. He was treated with rifampin, ethambutol, and clarithromycin. Antimycobacterial drug therapy was stopped in January 2002. A subsequent chest radiograph in May 2002 showed worsening of a left upper lobe infiltrate and antimycobacterial drug therapy was reinstituted.

The chest radiograph on admission showed multiple cavities in the right upper lobe with an intracavitary mass and air crescent in a proximal cavity, volume loss in the right upper lobe, and a peripheral cavitary nodule in the left upper lobe (Fig. 1). Computed tomography of the chest showed an intracavitary mass in the posterior segment of the right upper lobe (Fig. 2).

FIGURE 1.

FIGURE 1.

FIGURE 2.

FIGURE 2.

Physical examination revealed a cachetic man in no acute distress. Breath sounds were diminished in both lung fields. Scattered expiratory rhonchi were heard in both lung fields. White blood cell count, platelet count, liver function tests, prothrombin time, and activated partial thromboplastin time were normal. Repeated sputum smears were positive for mycobacteria. Initially, he received broad-spectrum antibiotic therapy in addition to the antimycobacterial drugs for presumed bacterial superinfection of the right upper lobe cavities. He underwent flexible fiberoptic bronchoscopy under topical anesthesia because of persistence of hemoptysis for a week after the institution of antibiotic therapy. Immediately distal to the orifice of the posterior segmental bronchus of the right upper lobe, a cavity lined by numerous mural nodules with overlying glistening mucosa was visualized (Fig. 3). Areas of mild bleeding were noted on the surface of some nodules. Washings from the cavity yielded mycelia consistent with Aspergillus (Fig. 4). Sputum culture grew Aspergillus flavus.

FIGURE 3.

FIGURE 3.

FIGURE 4.

FIGURE 4.

He was started on 200 mg itraconazole twice daily. Hemoptysis resolved 3 days after the institution of itraconazole.

When discharged from the hospital, he was transferred to a skilled nursing facility and continued itraconazole and antimycobacterial drug therapy. Three months later, repeated chest radiograph (Fig. 5) and computed tomography of the chest (Fig. 6) showed complete resolution of the intracavitary mass in the right upper lobe. Sputum culture for Aspergillus species was negative. Itraconazole was discontinued after 4 months of therapy. He did not have any recurrence of hemoptysis during several months of follow up.

FIGURE 5.

FIGURE 5.

FIGURE 6.

FIGURE 6.

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DISCUSSION

The diagnosis of aspergilloma is usually made based on the characteristic radiographic findings of a mobile intracavitary mass associated with an air crescent (Monad's crescent) and serum precipitins against Aspergillus species. 5,6 Corroborative evidence is obtained by a positive sputum culture for Aspergillus species. Bronchoscopic evaluation is reserved for verification of the bleeding source during persistent hemoptysis associated with an aspergilloma and for intracavitary instillation of amphotericin B. Another indication for bronchoscopy is to exclude an alternate source of bleeding such as bronchogenic carcinoma.

Bristowe reported one of the earliest cases of aspergilloma in an autopsy. 7 Reports of bronchoscopic visualization of aspergilloma are rare. 8–11 A large cavity in communication with a segmental bronchus allowed us to visualize the aspergilloma in this instance.

The optimal treatment of aspergilloma is controversial. Glimp et al. have reviewed the various therapeutic modalities for aspergilloma. 5 Intravenous or intracavitary amphotericin B has been associated with variable results. Endobronchial instillation of antifungal agents has been of minimal benefit. 12,13 Patients with massive hemoptysis are candidates for emergency surgery, provided the underlying pulmonary disease permits resection. 14 A conservative approach is recommended in asymptomatic patients and those with mild to moderate hemoptysis. 15 The prognosis of pulmonary aspergilloma depends primarily on the nature and severity of the underlying lung disease.

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ACKNOWLEDGMENTS

The authors thank Allen R. Thomas, MD, and Ifat Shah, MD, for expert assistance in digital formatting of the radiographs and histology, respectively.

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REFERENCES

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Keywords:

aspergilloma; mycobacterium avium/intracellulare; fungus ball

© 2003 Lippincott Williams & Wilkins, Inc.