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Pictorial Essay

Pulmonary Aspergillosis: Imaging Findings with Pathologic

Correlation
Suzanne L. Aquino,1 Stephen T. Kee,1 Martha L. Warnock,2 and Gordon Gamsu1

Pulmonary involvement with Aspergilus fumigatus is varied chymal opacities of this allergic pneumonia may be difficult
and largely dependent on the patient’s underlying pulmonary to distinguish from a bacterial pneumonia or lung abscess,
and immune status. Hypersensitivity reactions from inhalation which can complicate the underlying bronchiectasis and
of spores can cause acute allergic alveolitis, and bronchial col-
chronic obstruction.
onization can cause allergic bronchopulmonary aspergillosis
Treatment for ABPA involves steroid administration, which can
(ABPA). The latter is found mainly in patients with asthma or
improve symptoms, decrease the hypersensitivity reaction, and
cystic fibrosis. Mycetomas develop from secondary coloniza-
tion of preexisting lung cavities. Invasive and semiinvasive
aspergillosis affect mostly patients with altered immune status
[1]. This essay illustrates the radiologic findings of pulmonary
aspergillosis and shows the correlation between the imaging
and pathologic findings.

ABPA is both a type I and type Ill hypersensitivity reaction to

Aspergillus colonizing the bronchial lumens. The classic signs
and symptoms include wheezing, eosinophilia, recurrent pul-
monary opacities, elevated serum levels of immunoglobulin E,
and immediate skin reactivity to Aspergillus antigen in a patient
with asthma [1]. The chest radiograph can show normal find-
ings or second- and third-order bronchi impacted with mucus,
hyphae, and cellular debris, giving a finger-in-glove appear-
ance (Fig. 1). With time, central bronchiectasis, commonly
bilateral, and lung fibrosis develop, which can be extensively
destructive. Mucous plugs may be transient or may persist for
months or years. Bronchial obstruction may cause secondary
atelectasis [2]; however, hyperinflation has been noted and
has been ascribed to collateral air flow.
Recurrent or transient parenchymal opacities can be the Fig. 1.-Allergic bronchopulmonary aspergiliosis and mucous plugs
result of an eosinophilic pneumonia (Fig. 2). These opacities in 16-year-old man with long-standing asthma and 4 years of intermittent
fever, cough, and wheezing. Blood and sputum samples showed cosine-
can be asymptomatic, exist for an extended time, or cavitate philia, and Aspergillus grew from sputum specimens. Chest radiograph
and develop a secondary mycetoma [2] (Fig. 3). The paren- shows thick finger-in-glove opacities (arrows) in left upper lobe.

Received March 1 6, March 1994; accepted after revision April 15, 1994.
1 Department of Radiology, University of California, San Francisco, San Francisco, CA 94143-0628. Address correspondence to S. L. Aquino.
2Department of Pathology, University of Califomia, San Francisco.
AJR 1994;163:811-815 0361-803X194/1634-811 ©American Roentgen Ray Society
 812 AQUINO ET AL.
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AJR:163, October 1994

limit the pulmonary damage. Chronic steroid use at high doses, chial tissue [4] or more aggressive parenchymal invasion can
however, may immunocompromise the patient. If colonization of result (Fig. 4). A key sign of invasion into the adjacent lung paren-
the lung occurs, a local granulomatous reaction in the peribron- chyma and its vasculature is hemoptysis, which can be fatal.

Fig. 2.-Allergic bronchopuimonary asper-

gillosls and mucous plugs In 26-year-old
woman with a history of asthma and recurrent
pneumonias.
A, Chest radiograph shows consolidation in
right mid lung.
B, Subsequent radiograph shows resolution
of opacity on right and a new opacity on left.
C, High-resolution CT scan (1 .5-mm collima-
tion) of thorax obtained later shows resolution
of pneumonia. Two rounded tubular masses in
left lower lobe are bronchi filled with mucus
and debris.
D, Follow-up CT scan after treatment with
steroids and antibiotics shows resolution of
mucous plugs and bilateral varicose bron-
chiectasis.

Fig. 3.-Complications ofaliergic bronchopulmonaryaspergillosis in 17-year- Fig. 4.-Complicatlons ofallergic bronchopulmonary aspergiliosis(ABPA).
old man with asthma since age 4 and prior resection of an aspergilloma in the Sliced surface of postmortem lung from 62-year-old man with ABPA who was
tight upper lobe. Chest radiOgraph shows central bronchiectasis (open arrow) on steroids and died from invasive disease. Cunied arrow shows proximal
and left upper lobe consolidation with air crescent (asrows) within consolidation bronchiectasis. Stralghtarrowsindicate a bronchus feeding into a cavity con-
consistentwith mycetoma(repdntedwlth permissionfrom Klein and Gamsu(3D. taming a lung ball. Vascular invasion caused massive hemoptysis and death.
 IMAGING AND PULMONARY ASPERGILLOSIS 813
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AJR:163, October 1994

Mycetomas chial arteries for hemorrhage, and surgical resection for cases
Mycetomas represent a saprophytic growth of Aspergillus of recurrent hemoptysis. Approximately 10% of mycetomas
that colonizes pulmonary cavities and are usually in the spontaneously resolve [1].
upper lobes. Preexisting cavities, cysts, and other air-con-
taming spaces predispose the individual to this superinfec-
Invasive Aspergillosis
tion (cavities of prior tuberculous infections are the most
common spaces). Other causes in decreasing frequency Invasive pulmonary aspergillosis (IPA) occurs in immuno-
include cysts and cavities from sarcoidosis, chronic fungal suppressed, neutropenic patients, most commonly with
infections, bronchiectasis, bullae, sites of prior surgery such hematologic malignancies, organ transplantation, burns, or
as lobectomy and pneumonectomies, pulmonary abscesses, diabetes mellitus. PA is the most common manifestation of
and bronchial cysts [1 5]. , widely disseminated Aspergillus infection in these patients.
Patients have a chronic productive cough or hemoptysis, IPA may manifest as a necrotizing pneumonia, hemorrhagic
which can be life threatening. Pleural thickening may be the pulmonary infarction (lung ball), abscess [6], or rarely, as a
earliest sign on chest radiographs before any visible changes membranous tracheobronchitis [7]. Because IPA is angioin-
in the involved cavity or cyst [1]. Classically, the cavity con- vasive, its presentation may mimic thromboembolic disease.
tainS a mobile rounded mass or fungus ball (Fig. 5), but other The reported mortality varies from 30% to 90%. Treatment is
findings of Aspergillus superinfection include thickening of most successful if initiated early [6]. Occasionally, an
the wall of the cyst or cavity, opacification (Fig. 6), or forma- Aspergillus abscess ruptures into the pleural space, causing
tion of an air-fluid level within the cyst [5]. These masses may an empyema (Fig. 7). Rare cardiac complications include
exist for years and can calcify. Pathologically, the walls con- pericarditis and endocarditis.
sist of fibrous tissue, inflammatory cells, and abundant yes- The findings on chest radiograph vary from normal in early
sels that may be the source of hemorrhage [5]. disease to focal or multifocal peripheral opacities (Fig. 8A)
Systemic antifungals and steroids have shown limited that can progress to larger areas of consolidation [1]. Although
results in treating mycetomas. Other therapies include intrac- not pathognomonic, within the clinical context of the case, the
avitary instillation of antifungal agents, embolization of bron- halo sign on CT is suggestive of invasive aspergillosis [8]. The

Fig. 5.-Mobile mycetoma in a cavitating

pulmonary rheumatoid nodule in 76-year-old
man with rheumatoid arthritis and a productive
cough. Sputum was positive for Aspergillus.
A, CT scan shows a cavitating nodule with
an air crescent (arrows).
B, CT scan with patient in the prone position
shows that air crescent (arrows) migrated as
fungus ball moved to dependent portion of
cavity.

Fig. 6.-Mycetoma in a 26-year-old woman with hemoptysis. Fig. 7.-Asperglllus empyema in 50-year-
A, CT scan shows bilateral apical fibrosis and a focal mass in right upper lobe. Central low-atten- old man with AIDS and cryptococcal meningi-
uation region is a mycetoma in a cavity confirmed at resection. tis. CT scan shows a right pleural effusion with
B, Section of a lung specimen from a similar case shows a central fungating mycetoma partially parletal pleural thickening associated with a
adherent to walls of a preexisting abscess cavity. necrotic pneumonia (consolidation with central
low attenuation). Cultures of fluid obtained at
thoracentesls grew Aspergillus.
 814 AQUINO ET AL. AJR:163, October 1994
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halo is a rim of ground-glass opacity surrounding the area of underlying noncavitary pulmonary disease (i.e., pulmonary
infection and corresponds to local hemorrhage from vascular fibrosis, emphysema), or are mildly immunosuppressed. Signs
invasion (Fig. 8B). and symptoms include fever, malaise, weight loss, chronic pro-
With healing, the central necrotic tissue shrinks and ductive cough, and, in some, hemoptysis.
retracts from the surrounding viable tissue creating an air Radiographs show an indolent mass (Fig. 1 0) or focal con-
crescent (Fig. 9). This crescent sign is a late feature and solidation (Fig. 11) with or without pleural thickening that tends
usually occurs after 2-3 weeks of treatment when the neu- to involve the upper lobes [9]. It may cavitate and develop a
tropenia has resolved. mycetoma. Spread may be to the entire lung, chest wall, or
mediastinum. Vascular invasion may cause hemoptysis.

Semlinvasive Aspergillosis
Other Thoracic Manifestations
Semiinvasive or chronic necrotizing aspergillosis is an indo-
lent focal process caused by superficial invasion of the lung In a nonimmunosuppressed patient, pulmonary aspergillo-
parenchyma [9]. Most patients are middle aged, have an sis can occasionally become manifest as a nonspecific soli-

Fig. 8.-invasive aspergillosis with halo

sign. This 22-year-old
woman with leukemia,
previously treated with chemotherapy and bone
marrow transplantation, had fever.
A, CT scan shows multiple nodular opacities
with surrounding halos. Despite antifungal ther-
apy, patient died of disseminated aspergillosis 1
month later.
B, Photomicrograph of histopathologic spec-
imen shows extensive hemorrhage (between
arrows) around wall of one of cavitating nodules.
C, Photomicrograph of another area shows
hyphae(a,mws)within walls and lumen (astarlsk)
of small bronchus.
D, Photomicrograph shows hyphae (arrows)
in wails of adjacent pulmonary artery (asterisk
In lumen).

Fig. 9.-Air crescent sign of invasive asper-

gillosis in 56-year-old man with acute lympho-
cytic pneumonia and blast crisis. After induction
chemotherapy, pneumonia developed, and he
required Intubation. Open lung biopsy did not
provide specific diagnosis.
A, Chest radiograph obtained 3 weeks after
biopsy shows air crescent (arrows) in consoli-
dation (arrows). Patient died of cardiac compli-
cations.
B, Section of lung specimen shows an orga-
nizing Aspergillus pneumonia wfth a central lung
ball consisting of necrotic pulmonary tissue.
 IMAGING AND PULMONARY ASPERGILLOSIS 815
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AJR:163, October 1994

A B
Fig. 10.-Semiinvasive aspergiliosis manifested by Fig. 11.-Consolidated semiinvasive aspergillosis in 24-year-old man with AIDS and
a focal mass. This 70-year-old man with prior resection chronic pulmonary opacity.
of right upper lobe chronic aspergiliosis had fever, A, High-resolution CT scan shows patchy consolidation in posterior part of right upper
weight loss, and a new mass in left upper lobe 2 years lobe of lung. Surrounding lung has diffuse emphysema and fibrosis.
later. CT scan shows poorly defined mass with small B, Photomicrograph of histopathologic specimen shows organizing pneumonia with
cavities (arrow) and spiculated borders. Mass was multiple necrotic foci (arrows) surrounded by granulation tissue. Scant hyphae are present
resected and found to be organizing pneumonia with in necrotic areas (not shown).
surrounding fibrosis consistent with recurrent semlin-
vasive aspergillosis.

tary nodule or mass indistinguishable from other fungal 4. Riley DJ, Mackenzie JW, Uhlman WE, Edelman NH. Allergic bronchopul-
monary aspergillosis: evidence of limited tissue invasion. Am Rev Respir
infections, granulomas, or malignant tumors.
Dis 197:111:232-235
5. Fraser RG, Pare JAP, Pare PD, Fraser RS, Genereux GP. Infectious dis-
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