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Aspergilloma

Intracav Aspergillus Fung Ball

An aspergilloma is a non-invasive, spherical mass of fungal hyphae, mucus and cellular debris that commonly grows in pulmonary or paranasal cavities. It occurs more frequently in patients with structurally abnormal lungs and is asymptomatic in most cases. Standard radiographic methods can diagnose this condition. In few cases, hemoptysis may occur. In such a setting, surgical removal and subsequent control examinations are imperative.


Presentation

Pulmonary aspergillomas are caused by a fungal infection with Aspergillus fumigatus, Pseudallescheria boydii, Cryptococcus neoformans, Candida or Mucorales, presenting as a clump in pre-existing pulmonary cavities. The disease can also occur in the paranasal cavities, the brain, the kidneys and other organs. A. fumigatus typically grows in decaying vegetation and in bird feces. Patients with previous, recurring or persisting episodes of tuberculosis, coccidioidomycosis, cystic fibrosis, histoplasmosis, lung abscess, primary or metastatic lung carcinoma, a human immunodeficiency virus (HIV) infection or sarcoidosis often exhibit an increased pulmonary cavity count. The lesions are most frequently reported after tuberculosis episodes [1] [2] [3] [4] [5].

The symptoms can be chest pain, coughing, fatigue, fever, and sudden and unexpected weight loss. If coughing episodes are accompanied by blood-stained expectoration, immediate action is required, since this symptom may indicate an erosion of bronchial artery [2]. The involvement of paranasal cavities may present with symptoms similar to rhinosinusitis. In more complicated cases, inflammation symptoms conducive to aspergillosis can occur, which leads to additional symptoms like jaundice [1].

Aspergilloma growth is determined by aspergillus mycelial growth that seeds at the pulmonary cavity wall, gradually spreading into the cavity lumen. Mycelial layers will accumulate and create a sponge-like spherical conglomerate over time. The mass can also be mobile within the pulmonary cavity. The surrounding bronchioles may be affected by the aspergilloma's volume, potentially causing bronchiectasis [6].

Fatigue
  • A 68-year-old male with orthotopic heart transplantation presented with fatigue, cough, and dyspnea.[ncbi.nlm.nih.gov]
  • Six years earlier, he had had a similar episode lasting 5 weeks, during which he had also had night sweats, weight loss, and fatigue. At that time, he was treated empirically for tuberculosis.[nejm.org]
  • The symptoms can be chest pain, coughing, fatigue, fever, and sudden and unexpected weight loss.[symptoma.com]
  • When symptoms do develop, they can include: Chest pain Cough Coughing up blood , which can be a life-threatening sign Fatigue Fever Unintentional weight loss Exams and Tests Your health care provider may suspect you have a fungal infection after x-rays[ufhealth.org]
  • Symptoms lasting more than 3 months, usually including weight loss, fatigue, cough, coughing blood (haemoptysis) and breathlessness A blood test or tissue fluid test positive for Aspergillus species Aspergilloma An aspergilloma is a fungal mass caused[aspergillus.org.uk]
Rales
  • On physical examination, his basal oxygen saturation was 98%; ectoscopy showed that he was emaciated and pulmonary auscultation revealed basal crepitant rales, prominent in the left hemithorax. Laboratory test results were normal.[archbronconeumol.org]
Abdominal Mass
  • We report a previously healthy 8-year-old boy who presented to the hospital with a palpable abdominal mass, fever and abdominal pain. CT and MRI scans confirmed a large mass that was centered in the retroperitoneum.[ncbi.nlm.nih.gov]
Dysphagia
  • A 63-year-old male with chronic lymphoid leukemia was admitted for dyspnea, cough, weakness, and dysphagia. Chest CT and bronchoscopy showed a mass causing obstruction of the subglottic trachea and a fistula to the mediastinum.[ncbi.nlm.nih.gov]
Gagging
  • Moreover, there is no lung protection against endobronchial spillage during the period of induction of general anesthesia, when the cough reflex and gag reflex are absent.[ncbi.nlm.nih.gov]

Workup

Aspergilloma diagnosis requires the proof of a fungal infection and the specific localization of the lesion using standard imaging techniques. Most frequent procedures to be ordered are blood tests probing the existence of or an immune response against A. fumigatus as well as a sputum culture and a lung biopsy [1].

Computed tomography (CT) scans and plain radiography examinations will provide exact information about a potential aspergilloma. Radiographic investigations will only yield satisfying resolution in advanced stages [7]. CT results typically feature a central soft tissue within a pulmonary or paranasal cavity, which is surrounded by an air crescent (termed Monad sign). The observed conglomerate is usually spherical or ovoid and mobile upon repositioning of the patient [8].

Asymptomatic aspergillomas do not require treatment. They resolve spontaneously in ten percent of reported cases [9]. Symptomatic cases should be treated by (video-assisted) surgical removal or a lobectomy in the case of a pulmonary aspergilloma. Surgery complications range from excessive bleeding and wound dehiscence to respiratory insufficiency [10].

Recurrence can occur, most likely in the setting of pre-existing chronic aspergillosis. Patients should be checked for regrowth with annual radiographic examinations. Antifungal therapies have shown limited effect in experimental treatments of selected cases [11].

Pulmonary Infiltrate
  • No evidence of transient pulmonary infiltrates has been documented. A diagnosis of concomitant aspergilloma and ABPA was suspected. A wedge resection of the left upper lobe was performed ( fig. 2 ).[err.ersjournals.com]
  • Pulmonary infiltrates do not respond to conventional antibiotics.[patient.info]
  • Because it is uncommon, CNPA often remains unrecognized for weeks or months and can cause a progressive cavitary pulmonary infiltrate.[emedicine.medscape.com]
Air Bronchogram
  • Imaging prior to presentation demonstrated mediastinal lymphadenopathy and coalescent parenchymal alveolar opacities along with air bronchograms, suggestive of alveolar sarcoidosis.[ncbi.nlm.nih.gov]
Aspergillus Fumigatus in the Sputum
  • Sputum examination was negative for acid fast bacilli and culture yielded Aspergillus fumigatus from three sputum samples. With a diagnosis of pulmonary aspergilloma, the patient was referred to a higher center for further management.[atmph.org]
  • Med Clin North Am 64:475–490 PubMed Google Scholar Pepys J, Riddell RW, Citron KM, Clayton YM, Short EI (1959) Clinical and immunologic significance of aspergillus fumigatus in the sputum.[link.springer.com]
Hepatocellular Carcinoma
  • The first patient was a 59-year-old white woman treated for a secondary lung nodule of an advanced hepatocellular carcinoma.[ncbi.nlm.nih.gov]

Treatment

  • Surgical treatment with lung resection has traditionally been the treatment of choice for pulmonary cavities containing aspergillomas that cause hemoptysis.[ncbi.nlm.nih.gov]

Prognosis

  • Our long-term follow-up study also revealed a favorable prognosis. Based on this experience, we suggest caspofungin acetate as first-line therapy for treatment plans of liver aspergilloma.[ncbi.nlm.nih.gov]
  • In many, the prognosis is good.[dovemed.com]

Etiology

  • No other etiology of sinus RAI uptake has been mentioned to date. We report five cases of DTC patients with sinus RAI uptake on post-RAI scintigraphy.[ncbi.nlm.nih.gov]

Epidemiology

  • Subsequently, we systematically reviewed 22 confirmed cases of pulmonary hydatid cyst and aspergilloma during a period of 19 years (1995-2014) and discussed the epidemiology, clinical features, and treatment of this disease.[ncbi.nlm.nih.gov]
  • Laboratory and Epidemiology Communications Anti-Fungal Chemotherapy for Symptomatic Pulmonary Aspergilloma Akihiko Kawana*, Yasuhiro Yamauchi and Koichiro Kudo Department of Pulmonology, International Medical Center of Japan, Toyama 1-21-1, Shinjuku-ku[www0.nih.go.jp]
  • Missing options of surgical treatment due to lack of resources and epidemiological concerns led to the decision to treat pharmacologically, first for tuberculosis and subsequently for pulmonary aspergilloma.[journals.plos.org]
  • Aspergilloma Epidemiology Aspergilloma has a variable prevalence depending on the amount of cavitating lung disease affecting a population.[patient.info]
Sex distribution
Age distribution

Pathophysiology

  • Such an event appears plausible theoretically because embolization cuts off nutrition to the fungal ball, which feeds out of the cavity walls it dwells in; however, it does not concur with the known pathophysiology of fungal ball that they occur because[ijri.org]
  • Keywords : Aspergilloma ; Pulmonary tuberculosis ; Hemoptysis INTRODUCTION Pulmonary aspergillosis, which is caused by Aspergillus fumigatus, can be classified into 5 categories according to its pathophysiology, clinical manifestation, and treatment modality[kjim.org]
  • Pathophysiology The aspergillus fungus is commonly found in sputum cultures ( 11 ). They invade the lung through the respiratory tract and colonize the pre-existing cavity which has a direct communication to a bronchiole ( 18 ).[jtd.amegroups.com]
  • Pathophysiology Invasive infections are usually acquired by inhalation of spores or, occasionally, by direct invasion through damaged skin.[merckmanuals.com]

Prevention

  • CONCLUSIONS: An early diagnosis of ISSA, although not easy, is important to prevent complications arising from extensions of these lesions beyond the sphenoid sinus.[ncbi.nlm.nih.gov]

References

Article

  1. Franquet T, Müller NL, Giménez A, et al. Spectrum of pulmonary aspergillosis: histologic, clinical, and radiologic findings. Radiographics. 2001; 21(4): 825-837.
  2. Farid S, Mohamed S, Devbhandari M, et al. Results of surgery for chronic pulmonary Aspergillosis, optimal antifungal therapy and proposed high risk factors for recurrence--a National Centre's experience. J Cardiothorac Surg. 2013; 8:180.
  3. Pandey P, Dixit AK, Tanwar A, Mahajan NC. Pulmonary echinococcal cyst with a filamentous fungus co-infection. Ghana Med J. 2013; 47(3):148-152.
  4. Smith NL, Denning DW. Underlying conditions in chronic pulmonary aspergillosis including simple aspergilloma. Eur Respir J. 2011; 37(4):865-872.
  5. Addrizzo-Harris DJ, Harkin TJ, McGuinness G, Naidich DP, Rom WN. Pulmonary Aspergilloma and AIDS : A Comparison of HIV-infected and HIV-Negative Individuals. Chest. 1997; 111(3):612-618.
  6. Hiraki T, Gobara H, Mimura H, et al. Aspergilloma in a cavity formed after percutaneous radiofrequency ablation for lung cancer. J Vasc Interv Radiol. 2009; 20:1499–1500.
  7. Roberts CM, Citron KM, Strickland B. Intrathoracic aspergilloma: role of CT in diagnosis and treatment. Radiology. 1987; 165(1):123-128.
  8. Franquet T, Lee KS, Muller NL. Imaging of pulmonary infections. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
  9. Hammerman KJ, Christianson CS, Huntington I, Hurst GA, Zelman M, Tosh FE. Spontaneous lysis of aspergillomata. Chest. 1973; 64:679–679.
  10. Chen QK, Chen C, Chen XF, Jiang GN. Video-assisted thoracic surgery for pulmonary aspergilloma: a safe and effective procedure. Ann Thorac Surg. 2014; 97(1):218-223.
  11. Freymond N, Le Loch JB, Devouassoux G, Harf R, Rakotomalala A, Pacheco Y. Aspergillus bronchitis and aspergilloma treated successfully with voriconazole. Rev Mal Respir. 2005;22(5-1):811-814.

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Last updated: 2019-07-11 22:18