Great imaging this week coming from Potpourr (we) case two weeks ago at the VA, click “see more” below for great discussion of case by Joey Harrington. Check back Friday for a challenging CXR.
A 38 year-old female presents with 1 month of cough, chest pain, and one episode hemoptysis (she says about 2 cups). She has a PMH significant for TB 6 years ago, but cannot convincingly describe her treatment course to you. She does say that the diagnosis was made after a cavitary lesion was incidentally noted in her LUL field on a CXR.
Her CT is shown below:
Remember to include your name/level of training in the answer for some chocolate, best differential wins this week
send interesting images/ECGs to firstname.lastname@example.org
What are the top three things on your differential?
- Tubercular re-activation
- Vascular complications: hypervascularity from bronchial arteries, a fistula or even (!!!) a Rassmussen’s aneurysm (which happens when a pulmonary artery is adjacent to a cavitary lesion)
- Bronchiectasis (unlikely given the amount of blood)
In this case, the patient was found to have chronic cavitary aspergillosis, with an IgE elevated to 500, BAL galactomannan of 0.78, and a BAL fungal complement positive for aspergillus. Interestingly, her induced sputum only grew normal respiratory flora—a good reminder that a negative sputum doesn’t necessarily mean that a patient doesn’t have aspergillus—up to 70% of patients with known invasive pulmonary aspergillus have negative sputum studies!
Aspergillomas typically occur in patients with normal immune function but structural abnormal lungs and pre-existing cavities: most commonly (and in this patient’s case) in a cavity of post-primary pulmonary tuberculosis. Other causes of cavitary lesions (and therefore potential aspergilloma sites) can be remembered using the mnemonic below:
C-ancer: mets or bronch. carcinoma (often SCC)
A-utoimmune: granulomas (Wegener’s, RA)
V-ascular: bland or septic pulm emboli
I-nfection: bacterial/fungal: abscess, Tb
Y-outh: bronchiogenic cyst, pulmonary sequestration, congenital pulmonary airway malformation
Aspergillomas are often asymmtomatic, but when they do present generally do so with hemoptysis. On imaging, you can appreciate a fungal ball that moves with changes in patient position and is surrounded by air. The fungal ball itself is (somewhat disgustingly) a collection of fungal hyphae, mucus and other cellular debris. Treatment of an aspergilloma (not always necessary if the patient is asymmtomatic) is generally with voriconazole or itraconazole, though they only improve symptoms in about 60% of patients. In those with massive hemoptysis or, most subtlely, who are young and have excellent pulmonary function, resection offers more definitive treatment.
For a fantastic review of aspergillus check out: http://err.ersjournals.com/content/20/121/156
As always, Radiopaedia is an excellent resource: