ASPERGILLOMA

Mentor :
dr. Henny Maisara Sipahutar, Sp. Rad

Prepared By:
Janifer Sebastian (150100196)

PROGRAM PENDIDIKAN PROFESI DOKTER

DEPARTEMEN RADIOLOGI
FAKULTAS KEDOKTERAN
UNIVERSITAS SUMATERA UTARA
2020
CASE REPORT
 SRBS, female, age 17 years 8 months, with a major
complaint of coughing up blood hemoptysis with
volume about 50-500 ml/times and after diagnostic
procedures diagnosed with right pulmonary
aspergilloma. This patient came with coughing up blood
for almost 5 years and pale in 1 month. For the first time
,the diagnosis was assumed as pulmonary tuberculosis,
but after several examination and laboratory findings
were not confirmed.
CASE REPORT
 The patient was treated in hospital for 18 days. On the
first day of treatment, anemia condition in laboratory
examination was found. Immunodeficiency profile for
anti-HIV was non-reactive, CD 4 was 35%, and CD 4
absolute was 407 cell/μL, which is still within normal
range. So, immunodeficiency was excluded in this case.
Unfortunately, titer of immunoglobulin G in this patient
did not performed, and this is the limitation of this case.
CASE REPORT
 On physical examination, were found symmetrical
fusiform, suprasternal retraction, right hemithorax
breath sound was weakened and left hemithorax breath
sound was normal. Thorax CT scan found solid mass
and increase air flow in right lung, and the result was
confirmed aspergilloma. The history of this patient was
respiratory symptoms, so it is concluded as noninvasive
aspergillosis.
CASE REPORT
 On September 6th, 2017 the patient took operative
thoracotomy bilobectomy for indication of right
pulmonary aspergilloma, duration of surgery was 7
hours 30 minutes, with the amount of bleeding ± 9000
cc. After the surgery patient was stabilized in a pediatric
intensive care unit for 7 days.During postoperative care,
the patient's condition is unstable with respiratory
disorders, the presence of active bleeding in WSD tube,
fever, hypoalbuminemia, hypocalcemia, and negative
fluid balance. FFP and PRC transfusion is done to treat
anemia and active bleeding conditions. On the 9th day,
the patient's treatment is improving. On the 10th day of
postoperative, the patient is planned to move to
inpatient room from PICU.
Figure 1. Chest X-Ray on July 24th, 2017.
Figure 2. CT-Scan on July 31st, 2017.
Figure 3. Chest X-Ray on August 27th 2017.

Figure 4. Chest X-Ray on Sept 7th (post-op).

CASE REPORT
 Amphotericin B is the most widely used drug as the first
effective drug of choice for severe fungal infections and some
systemic mycoses.
 In this case, anti-fungal was given pre and post-operative,
because it was not complete resection, and to prevent
recurrence. We gave fluconazole based on availability in our
hospital.
 Previous reports suggest that surgical resection for aspergilloma
should be restricted to patients with severe hemoptysis who
have adequate respiratory function.
 In this case, surgical indication based on clinical
manifestation, coughing up blood that happen in 5 years
and become worsen day by day. Antifungal therapy alone
did not showed improvement. So, we decided to perform
surgical intervention, and continue antifungal after
surgery. After 7 days at Pediatric ICU, this patient got
improvement. The long-term results of surgical treatment
for aspergilloma are encouraging. The rate of 5-year
survival oscillates between 85% and 93%.
 Surgery results are good in terms of the low rate of
recurrence and long-term survival. This patient requires a
long-term follow-up.
ASPERGILLOMA
Definition
Aspergilloma is the most common and best known form of lung
involvement by the Aspergillus species, and usually develops in
cavities that have already existed in the lungs. Aspergilloma (fungus
ball) consists of fungal hyphae, inflammatory cells, fibrin, mucus,
and tissue debris.
Aspergilloma is a solid mass formless of fungal mycelium that can
sometimes be found with residual cavity in the lungs due to
tuberculosis, sarcoidosis, bronchiectasis, pneumokoniosis or
ankylosing spondylitis. Fungus ball is often found at the location of
the upper lobe of the lung.
Etiology
Aspergillosis is an infection caused by saprophyte molds of the
genus Aspergillus, can be found in decaying soil, water and plants
and Aspergillus species that often cause infections in humans, namely
Aspergillus fumigatus
 Pathophysiology
 Human host defense against
the inhaled spores begins with
the mucous layer and the ciliary
action in the respiratory tract.
 Macrophages and neutrophils
encompass, engulf, and
eradicate the fungus.
 However, many species of
Aspergillus produce toxic
metabolites that inhibit
macrophage and neutrophil
phagocytosis.
 Corticosteroids also impair
macraphage and neutrophil
function.
Clinical Signs
 Some aspergillomas are asymptomatic and seen as an
incidental finding on radiographic studies.
 most common symptom associated with simple
aspergilloma is hemoptysis
 Other associated symptoms are fever, weight loss,
malaise, and clubbing (may be associated with the
underlying lung disease itself).
 Radiographic findings

Chest Radiography
Chest Radiography
 Chest radiography is useful in
demonstrating the presence of
a mass in a pre-existing cavity.
Aspergilloma appears as an
upper-lobe, mobile, intra-
cavitary mass with an air
crescent in the periphery
 Aspergiloma on chest
radiograph appears as an
opaque lesion surrounded by
air in a cavity called a fungus
ball
 CT Scan

Computed Tomography (CT)

Scan
 Chest CT scan may be
necessary to visualise
aspergilloma that is not
apparent on chest
The CT image shows the right upper lobe with
radiograph aspergilloma in patients with sarcoidosis.

Aspergilloma in chronic cavitation pulmonary

aspergillosis. Fungus ball appears as a solid
oval mass of the upper left lobe partly
surrounded by crescents of water, the "air-
crescent" sign
 CT Scan

Aspergilloma: demonstration of mobility of fungus ball on axial computed

tomography (CT). (A) Supine image from axial CT reveals a left upper lobe cavity
with a fungus ball (arrow) (B) Prone image (same level) shows that the internal
opacity is mobile (arrow), characteristic of mycetoma.
Diagnosis of Aspergilloma

Nonradiographic diagnostic Differential Diagnosis

support can be performed
with sputum culture for
positive Aspergillus sp  Lung Abscess
Serum IgG antibodies to  Lung Tumor
Aspergillus are positive in  Tuberculosis
many cases but may be
negative in patients taking
corticosteroid therapy
Treatment
Treatment is considered only when patients become symptomatic,
usually with haemoptysis
CT-guided percutaneous administration of amphotericin B can be
effective for aspergilloma, especially in patients with massive
haemoptysis, and can lead to resolution within few days
Itraconazole may be useful in the management of selected patients
with aspergilloma because it has a high tissue penetration.
Surgical resection of the cavity and removal of the fungus ball is
usually indicated in patients with recurrent haemoptysis, if their
pulmonary function is sufficient to allow surgery
Bronchial artery embolisation should be considered as a temporary
measure in patients with life-threatening haemoptysis
Prognosis

 Even in asymptomatic patients, aggressive surgery offers 5

potential benefits: prevention of hemoptysis, eradication of
the fungal and possible pyogenic component, limitation of
symptoms as the result of a possible evolution to invasive
aspergillosis or increased growth of the mycetoma,
improvement of quality of life, and prolongation of life.
Because pulmonary aspergilloma is a benign disease, the
risk of early postoperative death should be avoided.
THANK YOU 