Aspergilloma

A.Prof Frank Gaillard et al.

Aspergillomas are mass-like fungus balls that are typically composed of Aspergillus fumigatus,
and are a non-invasive form of pulmonary aspergillosis.

Terminology

Although the term mycetoma is frequently used to describe these fungal balls, it is an incorrect
term to use 5-6.

Epidemiology

Aspergillomas occur in patients with normal immunity but structurally abnormal lungs, with pre-
existing cavities. Demographics will therefore match those of the underlying condition, such as 2:

pulmonary tuberculosis: most common, accounting for 25-80% of cases depending on the
prevalence of tuberculosis in the population 2-3

pulmonary sarcoidosis

bronchiectasis from any cause

other pulmonary cavities

o bronchogenic cyst 4

o pulmonary sequestration

o PJP associated pneumatocoeles

Clinical presentation

Most aspergillomas are asymptomatic. Occasionally due to surrounding reactive vascular

granulation tissue, haemoptysis may be present. Occasionally, erosion into a bronchial artery
may lead to life-threatening haemoptysis 1.

Pathology

An aspergilloma is a mass-like collection of fungal hyphae, mixed with mucous and cellular
debris, within a cavity the walls of which demonstrate vascular granulation tissue 1-2.

Distribution
Aspergillomas typically occur in the cavities of post-primary pulmonary tuberculosis. Therefore,
they are most frequently found in the posterior segments of the upper lobes and the superior
segments of the lower lobes.

Radiographic features

A mycetoma can be seen on both plain film and CT as an intracavitary mass surrounded by a
crescent of air. The term "air-crescent" is however really seen in recovering invasive pulmonary
aspergillosis. It is wrongly used by many to describe the air around an aspergilloma. The correct
term to describe the crescent of air is the Monad sign in the setting of aspergilloma developing in
a pre-existing cavity, although it is less widely recognised.

Plain radiograph

Aspergillomas typically appear as rounded or ovoid soft tissue attenuating masses located in a
surrounding cavity and outlined by a crescent of air 1-4. Altering the position of the patient
usually demonstrates that the mass is mobile, thus confirming the diagnosis.

CT

Appearances are those of a well formed cavity with a central soft tissue attenuating rounded
mass surrounded by a crescent of air (Monad sign). The mass is typically spherical or ovoid. On
different positioning of the patient, the mass can be shown to be mobile. On occasion the mass
may entirely fill the cavity, thus taking on the shape of the cavity, obliterating the surrounding air
crescent and no longer being mobile 2.

Calcification is not uncommon, which can range from none to heavy. Due to the inflammation
and vascular granulation tissue formation, the bronchial arteries supplying the wall can
sometimes be seen as markedly enlarged 2.

The adjacent pleura may well be thickened.

Treatment and prognosis

An asymptomatic aspergilloma does not necessarily require treatment, and the cavity is
essentially isolated from any systemic administration of anti-fungals 3.

In the setting of brisk haemoptysis, angiography may be performed on an emergency basis and
selective bronchial artery embolisation can be life saving. Failing this, or in cases of repeated
haemoptysis surgical excision with a lobectomy remains the gold standard 3.

Mortality rate varies widely, but in more recent series is low, even where requiring surgery 3.

Differential diagnosis

When classical in appearance there is little differential. If the mass fills the cavity completely
then the differential is that of solitary pulmonary nodule.
https://radiopaedia.org/articles/aspergilloma