11/18/2017 Chronic necrotising pulmonary aspergillosis | Radiology Reference Article | Radiopaedia.

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Chronic necrotising pulmonary aspergillosis

A.Prof Frank Gaillard ◉ ◈ et al.

Chronic necrotising aspergillosis (CNA), also known as semi-invasive aspergillosis, is, as the name suggests,
a chronic localised and indolent form of invasive aspergillosis.

On this page:
Article:

Epidemiology
Clinical presentation
Pathology
Radiographic features
Treatment and prognosis
History and etymology
Differential diagnosis
References

Epidemiology

CNA typically occurs in patients with a depressed immune system, but not as profoundly immunocompromised
as bone marrow patients who more frequently develop angioinvasive aspergillosis. Patients are typically middle-
aged. Risk factors, therefore, include 1-3:

corticosteroids - most common systemic immunodepressant 3

diabetes mellitus
alcoholism
chronic liver disease
malnutrition
connective tissue diseases such as rheumatoid arthritis and ankylosing spondylitis
pre-existing pulmonary pathology - present in ~80% of patients 3
COPD - most common
neoplasm with prior radiation therapy
sarcoidosis or other granulomatous diseases
pulmonary infarction
previous pulmonary tuberculosis
pulmonary fibrosis or previous surgery

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pneumoconiosis 5
advanced age

Clinical presentation

Typically patients present with progressive respiratory and constitutional symptoms (often for few months)
including fever, weight loss, cough, sputum production and haemoptysis 2-3.

Diagnosis is not always straight forward, as both bronchial washings and biopsy have a low diagnostic yield 3.

Pathology

Although the end result of chronic necrotising aspergillosis (CNA) is similar to an aspergilloma, it represents a
different process. Rather than Aspergillus colonising a pre-existing cavity, in CNA a focally invasive
aspergillosis occurs which eventually undergoes central necrosis and cavitation forming its own cavity. It is the
finding of tissue invasion that allows this entity to be distinguished from the more common aspergilloma 2,5.

The presence of calcium oxalate crystals suggests that Aspergillus niger is the causative agent 3.

Serological markers

The vast majority of patients with CNA have positive serum immunoglobulins (Ig)G antibodies to A. fumigatus
7.

Radiographic features

Radiographic appearance varies according to when the condition is imaged. Typically CNA involves the upper
zones and begins as a pulmonary opacity. Eventually, the central necrotic area separates away from the
surrounding lung and thus forms an air crescent sign. This occurs of weeks to months, eventually resulting in a
cavity with or without a central mycetoma 3. Appearances may then be the same as an aspergilloma. Often there
are multiple cavities, often thick-walled 2. Adjacent pleural thickening is often present 2-3.

It is similar in appearance to tuberculosis, actinomycosis, and histoplasmosis 2.

Treatment and prognosis

CNA usually runs a slowly progressive course over weeks to months, and vascular invasion or dissemination to
other organs is unusual.

During initial phases of the disease, anti-fungals are the mainstay of treatment. Intravenous and intracavitary
amphoterin B, 5-flucytosine (5-FC) and itraconazole have all been tried 3.

Surgery is reserved for patients who do not respond to initial medical management and have an adequate
pulmonary reserve and acceptable operative risks 3,5.

Once the disease has ceased progressing treatment is the same as that of an aspergilloma 1.

Prognosis is largely dictated by underlying lung disease and co-morbidities with mortality ranging from < 10%
to 39% depending on criteria for diagnosis and treatment administered 3.

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History and etymology

It was first described by Gefter et.al. and Binter et.al. in 1981 7.

Differential diagnosis

Possible imaging differential considerations include:

angioinvasive aspergillosis - usually obviously different due to patient demographics

aspergilloma
other infections
pulmonary tuberculosis
pulmonary actinomycosis - see thoracic actinomycosis infection
pulmonary histoplasmosis
malignancy (e.g. cavitating squamous cell carcinoma)
non-infective granulomatous disease

References
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