A 41-year-old man with a past history of tuberculosis presented to the emergency department with massive hemoptysis. The patient denied fever or chills but reported a 20-lb weight loss and intermittent hemoptysis during the last 6 months. Six years ago, he had been treated for tuberculosis.
Physical examination revealed fine crepitations in the left upper zone and generalized wasting. The patient was admitted to the hospital, where sputum studies revealed no predominant bacterial type and three negative acid-fast bacillus smears. However, the sputum culture showed light growth of Aspergillus fumigatus.
Dr Muhammad-Fuad Bangash of Chicago ordered a chest film, which showed marked fibrosis and cavitation in the left upper lobe, and a CT scan, which demonstrated an aspergilloma, or fungus ball, surrounded by a crescent of air in the posterior aspect of the upper lobe. Bronchoscopy revealed blood trickling from the lobe.
Aspergillosis is a secondary saprophytic colonization of preexisting pulmonary cavities that is most commonly seen in patients with a history of chronic lung disease, such as tuberculosis, sarcoidosis, or emphysema. Dr Bangash adds that hemoptysis occurs in 55% to 85% of patients with aspergilloma and can run the gamut of severity from blood-streaked sputum to active bleeding that requires urgent surgical intervention. Other pulmonary diseases caused by Aspergillus organisms are invasive aspergillosis, allergic bronchopulmonary aspergillosis, and chronic necrotizing pulmonary aspergillosis.1
Sputum cultures are positive in half to two thirds of patients with the disease and are suggestive but not diagnostic. Chest films and CT scans usually show the characteristic intracavitary mass partially surrounded by a crescent of air. Serum precipitins can be found in 90% of patients with fungus balls and suggest the diagnosis when accompanied by the characteristic radiographic appearance.
The natural history of aspergilloma is variable, and therapy must be individualized based on symptoms and underlying pulmonary status. Dr Bangash emphasizes that a conservative approach is prudent; observation alone is indicated for asymptomatic patients and those with mild, infrequent hemoptysis. Spontaneous disappearance or lysis of aspergillomas has been reported in up to 10% of cases.2
Studies have shown that some patients respond to itraconazole.3-5 Surgical resection, however, is clearly indicated for patients with severe hemoptysis, such as the patient discussed here.
Despite the recurrent nature and severity of his hemoptysis, this patient refused surgical resection and was discharged after receiving itraconazole.