Respiratory Medicine CME 3 (2010) 62–64

Contents lists available at ScienceDirect

Respiratory Medicine CME

journal homepage: www.elsevier.com/locate/rmedc

Case Report

Aspergilloma in preexisting cavity – serial chest roentgenograms

can help in diagnosis
Mohammad Shameem a, *, Nazish Fatima b, Rakesh Bhargava a, Zuber Ahmad a, Abida Malik b
a
Department of Tuberculosis and Chest Diseases, Jawaherlal Nehru Medical College, Aligarh Muslim University, Aligarh, UP 202002, India
b
Department of Microbiology, Jawaherlal Nehru Medical College, Aligarh Muslim University, Aligarh, UP 202002, India

a r t i c l e i n f o a b s t r a c t

Article history: A 24-year-old male presented with hemoptysis, off and on, which was gradually increasing. The patient
Received 13 May 2009 had four chest roentgenograms, which depicts various stages of aspergilloma formation in preexisting
Accepted 14 May 2009 cavity. The diagnosis of aspergilloma was made and patient underwent lobectomy.
Ó 2009 Elsevier Ltd. All rights reserved.
Keywords:
Aspergilloma
Chest X-Ray
Cavity

1. Introduction
The term mycetoma is used to describe a mobile fungus ball
within a preexisting, usually fibrotic, lung cavity. Mycetomas are
usually caused by Aspergillus (aspergilloma), but other fungi may
occasionally be responsible including Candida, streptomycetes,
coccidioides and phycomycetes.1 Aspergillomas consist of a tangled
growth of Aspergillus hyphae admixed with mucous and cellular
debris in a cavity. The cavity wall is often thick and consists of
a zone of fibrotic tissue, with necrosis of the inner layer.2,3 The
cavity wall has a rich blood supply from the bronchial and other
branches of the systemic circulation, and thus has a propensity to
bleed.4
2. Case report
L28, E12. Sputum culture for bacteria was negative, Sputum for Acid
Fast Bacillus was negative, Tuberculin test was negative. The patient
had four serial Chest X-Rays (PA-View)
i) Chest X-Ray (PA-View) shows a big cavity in right upper zone
(Fig. 1)
ii) Chest X-Ray (PA-View) shows an increase in wall thickness of
the fibrotic cavity (Fig. 2)
iii) Chest X-Ray (PA-View) shows opacity occupying inferior
margin of the cavity (Fig. 3)
iv) Chest X-Ray (PA-View) shows opacity occupying most of the
cavity lumen, with air around the mass (Fig. 4). Serological
test for Aspergillus precipitin was positive. Transthoracic fine-
needle aspiration biopsy shows intertwined Aspergillus
hyphae matted together with fibrin, mucus, and cellular
debris.

A 24-year-old male, presented with history of hemoptysis off

and on and shortness of breath on exertion, he had prior history of
expectoration of black colored sputum. He had taken anti tuber-
cular treatment four years back and was declared cured. After that
he was on treatment for hemoptysis from some local village prac-
titioner. He was referred to us for hempotysis. The patient was non-
smoker, and there was no history of any other illness. Physical
examination did not reveal any abnormality. The following inves-
tigation were done Hb% 8 gm%, TLC 6500/cu mm, and DLC: P60,
* Corresponding author. Tel.: þ91 9412731835.
E-mail address: doctor_shameem123@rediffmail.com (M. Shameem).
The patient was managed conservatively with antitussive and
hemostatic agents, after few weeks when bleeding subsided, he
underwent lobectomy.
3. Discussion
The typical radiographic appearances are of a rounded mass
sitting inside a cavity (usually thick walled), with air around the
mass. The mass is seen to gravitate freely on images of the patient
in different positions.3 The air-crescent sign is often considered to
be characteristic of mycetomas but has also been described in

1755-0017/$36.00 Ó 2009 Elsevier Ltd. All rights reserved.

doi:10.1016/j.rmedc.2009.05.011
 M. Shameem et al. / Respiratory Medicine CME 3 (2010) 62–64
Fig. 1. Chest X-Ray (PA-view) shows large cavity in right upper zone, with fibrosis.
Fig. 2. Chest X-Ray (PA-View) shows thickening of the wall of the cavity (antedating
the detection of fungus ball).
bronchogenic carcinoma,5 retained foreign body following thora-
cotomy,6 haemorrhage into a cavity,7 Wegener’s granulomatosis,
sclerosing haemangioma,8 echinococcal cyst,9 tuberculosis, and
Rasmussen aneurysm in a tuberculous cavity. Confusingly, the air-
crescent sign may also be seen in angioinvasive aspergillosis,
where it corresponds pathologically to a space caused by retraction
of an area of retracted infarcted lung.10 An early sign of aspergil-
loma formation in a cavity is pleural thickening which often
antedates the radiographic features of an obvious intracavitary
fungus ball.11 An increase in wall thickness of the lateral aspect of
a fibrotic cavity (Fig. 2), reflecting a combination of pleural and
cavity wall thickening, may be a helpful sign of radiographically
cryptic aspergilloma.12 This feature is a reactive phenomenon, with
regression of the aspergilloma leading to a normalisation of the
pleural thickness.13 Thin-section CT can demonstrate the early
stages of aspergilloma much more readily than chest radiog-
raphy.14 Fungal fronds can be seen arising from the cavity wall,
often intersecting each other. These fronds coalesce and break
away from the cavity wall to form a mature fungus ball which may
contain small foci of high attenuation, presumably representing
calcifications15 (Fig. 4).
63
Fig. 3. Chest X-Ray (PA-View) aspergilloma attached to the wall of the cavity.
Fig. 4. Chest X-Ray (PA-view) shows 1–2 cm rounded aspergilloma, with typical
air-crescent sign.
Conflict of interest statement
Funded by Council for Science and Technology, UP India, as a part of
research project under young scientist scheme to Dr. Mohammad
Shameem.
Ethical consideration
This article is not published nor under consideration in any
journal. There is no ethical consideration involved in this case report.
References
1. Gefter WB. The spectrum of pulmonary aspergillosis. J Thorac Imaging
1992;7:56–74.
2. Franquet T, Müller NL, Gimenez A, Guembe P, de La TJ, Bague S. Spectrum of
pulmonary aspergillosis: histologic, clinical, and radiologic findings. Radio-
graphics 2001;21:825–37.
3. Hemphill RA. Mycotic lung infection. Am J Med; 1946::708–9.
4. Regnard JF, Icard P, Nicolosi M, Spagiarri L, Magdeleinat P, Jauffret B, et al.
Aspergilloma: a series of 89 surgical cases. Ann Thorac Surg 2000;69:898–903.
5. Cubillo-Herguera E, McAlister WH. The pulmonary meniscus sign in a case of
bronchogenic carcinoma. Radiology 1969;92:1299–300.
64 M. Shameem et al. / Respiratory Medicine CME 3 (2010) 62–64
6. Nomori H, Horio H, Hasegawa T, Naruke T. Retained sponge after thoracotomy
that mimicked aspergilloma. Ann Thorac Surg 1996;61:1535–6.
7. Bard R. Crescent sign in pulmonary hematoma. Radiology 1975;32:247–51.
8. Bahk YW, Shinn KS, Choi BS. The air meniscus sign in sclerosing hemangioma of
the lung. Radiology 1978;128:27–9.
9. Evans WA. Echinococcus cyst of the lung. Radiology 1943;40:362–6.
10. Stivelman BP. Rasmussen aneurysm: its roentgen appearance; report of case
with necropsy. J Am Med Assoc 1938;110:1829–31.
11. Curtis AM, Smith GJ, Ravin CE. Air crescent sign of invasive aspergillosis.
Radiology 1979;133:17–21.
12. Libshitz HI, Atkinson GW, Israel HL. Pleural thickening as a manifestation of
Aspergillus superinfection. Am J Roentgenol Radium Ther Nucl Med 1974;120:883–6.
13. Sansom HE, Baque-Juston M, Wells AU, Hansell DM. Lateral cavity wall thick-
ening as an early radiographic sign of mycetoma formation. Eur Radiol
2000;10:387–90.
14. Franquet T, Gimenez A, Cremades R, Domingo P, Plaza V. Spontaneous revers-
ibility of ‘‘pleural thickening’’ in a patient with semi-invasive pulmonary
aspergillosis: radiographic and CT findings. Eur Radiol 2000;10:722–4.
15. Roberts CM, Citron KM, Strickland B. Intrathoracic aspergilloma: role of CT in
diagnosis and treatment. Radiology 1987;165:123–8.