IMAGING COLUMN

Imaging diagnosis of aspergilloma

Chantal Youssef, MD1 and David M. Widlus, MD2*
1
Department of Medicine, Union Memorial Hospital, Baltimore, Maryland, USA; 2Department of
Radiology, Union Memorial Hospital, University of Maryland School of Medicine, Baltimore,
Maryland, USA

Received: 30 January 2012; Revised: 9 March 2012; Accepted: 14 March 2012; Published: 30 April 2012

55-year-old man with Human Immunodeficiency lung disease such as a prior pneumocystis jirovecci

A Virus (HIV) infection and Acquired Immunode-

ficiency Syndrome (AIDS), has a history of non-
compliance to antiretroviral therapy with recurrent
opportunistic infections due to clostridium difficile and
mycobacterium avium complex. He presented to the
hospital with fever, diarrhea, weight loss and generalized
weakness, and was diagnosed with clostridium difficile
colitis and treated as such. His absolute CD4 count was
153 cells/microliter and HIV1-RNA 2,190 copies/mL.
Chest radiograph showed a left upper lobe lung cavity
containing a soft tissue component of 4 cm compatible
with mycetoma (Fig. 1). This finding was subsequently
confirmed by a chest CT scan (Figs. 2a,b,c).
Aspergillus is a common saprophyte living in the soil
and plants, transmitted to humans by inhalation. Tissue
invasion is uncommon and occurs most frequently in the
setting of immunosuppression. In HIV-infected patients,
aspergillosis is mostly seen in untreated patients with
advanced AIDS. One of the risk factors for aspergillosis
in HIV-infected patients is the presence of underlying
pneumonia or cavitary disease.
The patient can have one of four different clinical
presentations:
(1) Invasive pulmonary aspergillosis with fever, cough,
dyspnea, pleuritic chest pain, anorexia and weight
loss.
(2) Tracheobronchial disease which can lead to exten-
sive inflammation and invasion of the tracheobron-
chial tree.
(3) Aspergilloma is a non-invasive form of colonization
by Aspergillus in a prior lung cavity, which is usually
asymptomatic but can present with fever, chest
pain, cough, hemoptysis, fatigue and weight loss.
The etiology is the contagious spore form of the
organism.
(4) Allergic bronchopulmonary aspergillosis, very rare
entity among HIV-infected patients.
This patient had the asymptomatic presentation of
aspergilloma which arose in a pre-existing lung cavity,
most likely secondary to his prior mycobacterium avium
complex infection. In this form the fungal spores are
typically inhaled into an established lung cavity where
they are able to multiply. Eventually a fungus ball
composed of aspergillus hyphae, inflammatory cells,
fibrin, mucus and cellular debris forms.
Diagnosis of aspergilloma is made by typical chest
radiographic and CT findings, in the correct clinical
setting, combined with sputum cultures or serum anti-
bodies to aspergillus.
The radiographic findings typical for aspergilloma
include:

(1) Cavitary lesion, most commonly in the upper lobes.

Wall thickening is a sign of secondary infection such
as with an aspergilloma.
Fig. 1. Left upper lobe cavitary area is seen with intra- (2) Intra-cavitary mass, with an air crescent sign, often
cavitary mass (arrow). PICC line is incidentally noted. easier to appreciate on CT scan than on Chest

Journal of Community Hospital Internal Medicine Perspectives 2012. # 2012 Chantal Youssef and David Widlus. This is an Open Access article distributed 1
under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting
all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: Journal of Community Hospital Internal Medicine Perspectives 2012, 2: 17276 - http://dx.doi.org/10.3402/jchimp.v2i1.17276
(page number not for citation purpose)
Chantal Youssef and David Widlus

Fig. 2. (a,b,c) Axial, coronal and sagittal CT scans of the chest show the intra-cavitary mass with surrounding air-crescent
(Fig. 2b arrow). The wall of the cavity is thickened (Fig. 2c arrow).

radiograph. The mass can often be seen to move Clinical and radiographic correlations. Chest 1994; 105(1): 37.
within the cavity with change in patient position. 2. Zmeili OS, Soubani AO. Pulmonary aspergillosis: A clinical
update. QJ Med 2007; 100: 317
34.
3. Franquet T, Muller NL, Gimenez A. et al. Spectrum
Treatment recommendations vary. Many patients with of pulmonary aspergillosis: Histologic, clinical and radiologic
a single aspergilloma, who are asymptomatic and findings. Radiographics 2001; 21: 825
37.
have stable radiographic findings over many months,
require only continued observation. Embolization or *David M. Widlus
surgical resection are usually offered to prevent or treat Department of Radiology
hemoptysis. Union Memorial Hospital
University of Maryland School of Medicine
Baltimore, Maryland
Conflict of interest and funding
USA
The authors have not received any funding or benefits Email: dwidlus@umm.edu
from industry or elsewhere to conduct this study.

Suggested readings
1. Miller WT Jr, Sais GJ, Frank I, Gefter WB, Aronchick JM,
Miller WT. Pulmonary aspergillosis in patients with AIDS.

2 Citation: Journal of Community Hospital Internal Medicine Perspectives 2012, 2: 17276 - http://dx.doi.org/10.3402/jchimp.v2i1.17276
(page number not for citation purpose)