Pulmonary aspergilloma

We report here a case of pulmonary aspergilloma that was diagnosed by sputum culture. The diagnosis of aspergilloma is most commonly based on the chest X-ray showing a cavity with an air-crescent sign and by histopathological examination of the resected tissue. However, in our case, the typical radiological sign was absent. A 36-year-old female patient presented with history of cough, breathlessness and hemoptysis. 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.

Keywords: Aspergillus fumigatus , diagnosis, pulmonary aspergilloma

Aspergilloma/Aspergillous mycetoma is the saprophytic colonization of the fungus in a pre-existing cavity of the lung. Aspergillus fumigatus is the most common causative agent. ^[1] Aspergilloma occurs in 10-15% of patients with cavitating lung diseases like tuberculosis, sarcoidosis, bronchiectasis, cysts and bullae. ^[2] The diagnosis is mainly by radiological findings of a mobile mass in a cavity by X-ray or computed tomography (CT) scan. Since it produces wide array of radiographic changes, the diagnosis becomes difficult sometimes. ^[3] The diagnosis is also established by histopathological examination and culture of the tissue. ^[4] We report here a case of pulmonary aspergilloma due to A. fumigatus in a pre-existing tubercular cavity that was primarily diagnosed by sputum culture. This case is reported to highlight the difficulties in diagnosis of pulmonary aspergilloma

A 36-year-old female was admitted in our hospital with complaints of cough with expectoration and breathlessness since 6 months, hemoptysis and evening rise of temperature since 1 week. She had suffered from pulmonary tuberculosis 3 years back for which she received complete course of antitubercular therapy. Examination of the respiratory system showed trachea shifted to right side and signs of cavitary lesion in the upper lobe of right lung. Chest X-ray revealed a cavitary lesion in the right upper lobe [Figure 1]. A diagnosis of fibrocavity lesion of right upper lobe and collapse of the right lower lobe of lung was made. Gram’s stain of the sputum sample showed gram-positive septate hyphae with dichotomous branching [Figure 2] and gram-positive budding yeast cells with pseudohyphae. Zeihl-Neelson’s staining did not reveal any acid fast bacilli in three sputum samples. Sputum culture yielded A. fumigatus and Candida non-albicans species from three repeat samples collected on consecutive days [Figure 3]. The patient was being treated with amikacin and ceftriaxone. However, with the culture report and a fibrocavity lesion of the lung, a diagnosis of aspergilloma was made. The patient was referred to higher center for further review.

Aspergilloma/fungus ball is one of the forms of pulmonary aspergillosis that occurs commonly in tubercular cavities. The other forms of pulmonary aspergillosis are allergic bronchopulmonary aspergillosis, chronic necrotizing aspergillosis and invasive aspergillosis. ^[4] Aspergilloma predominantly occurs in the upper lobes, indicating the predilection for cavity formation at this site. ^[3] The natural history of aspergilloma varies from a stable lesion to progression and even spontaneous regression in about 5% of the cases. ^[4]

The definitive diagnosis is established by histopathological demonstration of dichotomously branching hyphae in resected specimen and culture of the tissue, but largely the diagnosis is based on radiological examination. The diagnosis of aspergilloma is mainly based on the presence of radiological opacity in the cavity with an air-crescent sign. Adjacent pleural thickening is the earliest sign on chest X-ray before the fungus ball appears. ^[3] Isolation of Aspergillus species from sputum, bronchial washings and intraoperative or postoperative examination of the fungal ball are other means of diagnosis. ^[1,5] A case of pulmonary aspergilloma that was diagnosed as bronchogenic carcinoma preoperatively has been reported by Osinowo et al. from Saudi Arabia. In their case, bronchial lavage, transbronchial biopsy and repeated examination of the sputum did not reveal any evidence of Aspergillus species. The diagnosis was established by intraoperative demonstration of fungal ball. ^[5] In our case, the diagnosis was established mainly by sputum culture because of the absence of classical radiological picture, which could be due to the early stage of the disease.

The most common clinical presentation in aspergilloma is hemoptysis, dyspnea, with or without fever, chest pain and weight loss. ^[6] Up to 25% of patients have massive hemoptysis. ^[2] Our patient presented with cough, hemoptysis and fever.

Massive hemoptysis is a common life-threatening complication of aspergilloma, necessitating surgical resection. ^[3],[7] Surgery (lobectomy) is the primary choice for treating pulmonary aspergilloma in spite of the risk of high morbidity and mortality. Systemic antifungal agents like Amphotericin B and Voriconazole have little role in the treatment of aspergilloma. ^[7]

Though the diagnosis of pulmonary aspergilloma is based on the radiological sign of air-crescent in a cavity, it can give rise to atypical radiological findings. This report highlights the difficulties in diagnosis of pulmonary aspergilloma preoperatively. Sputum and bronchial washing examination with strong clinical suspicion can help in diagnosis.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.77192

[Figure 1], [Figure 2], [Figure 3]