Prof.S.Sundar Unit

Present histroy

c/o hemoptysis-10epi 50-100ml/epi c/o cough and sputum-1month No h/o fever No h/o breathlessness No h/o chest pain No h/o LOW/LOA Noh/o hematuria No h/o hematemesis No h/o anticoagulation intake

Past histroy

No past h/o hemoptysis h/o treated PT one year before

Smoker Not a k/c of DM/SHT/CAD/ COPD

Non alcoholic

General examination

Conscious, oriented Afebrile Halitosis + No pallor No clubbing No cyanosis No pedal edema Not dyspneic No significant lymphadenopathy

Systemic examination

R.S-trachea midline flat chest cavernous BBS + left

infraclavicular

region B/L coarse crepts +Other system examination- normal

Investigations

CBC-WNL RFT -WNL Urine R/E- WNL ECG-WNL Sputum AFB-negative SputumC/S-Klebsiella sensitive

to amikacin,ciprofloxcine Serum IgE level- normal

Chest x-ray left UL cavity with

homogenous opacity within the cavity with semilunar air shadow CT Thorax conglumerate fibrotic mass Lesion doesnot enhance with

contrast-S/O Aspergilloma

Fungal c/s A.fumigatus grown in cultureKOH mount branching hyphal fragment

of aspergillus seenAspergillus precipitin test-positiveHIV/VDRL-nonreactive

DIAGNOSIS

Old treated pulmonary TB

Left upper lobe cavity Aspergilloma

CT-Surgery opinion left upper lobe aspergilloma Advised medical management

Chest medicine opinion Advised oral antifungal

TREATMENT

C.Itraconazole 100mg 2bd Packed RBC one unit Bronchodilator Inj.adrenochrome Inj.ciprofloxcin 200mg iv bd Bronchial arterial embolization

DISCUSSION ON ASPERGILLOSIS

CAUSED BY

A. fumigatus-most common A.flavus A.niger A.terreus A nidulans-immunocompromised

SPECTRUM OF PULMONARY ASPERGILLOSISHYPERSENSITIVITY REACTION Allergic bronchial asthma ABPA Extrinsic allergic alveolitis Bronchocentric granulomatosisINVASIVE INFECTION Invasive bronchial aspergillosis Chronic necrotizing pulmonary aspergillosis Invasive pulmonary aspergillosis Bronchial stump aspergillosisSAPROPHYTIC GROWTH IN PREEXISTING CAVITYSIMPLE COLONISATION

ASPERGILLOMA

Saprophytic colonization of Aspergillus in parenchymal lung cavity

Fungal ball lie free within the cavity or attached to cavitywall by granulation tissue

SECONDARY ASPERGILLOMA

Colonization and proliferation of fungus in a preexisting lung cavity

Tuberculosis cavity Sarcoidosis Histoplasmosis Blastomycosis AIDS pneumonia Lung abscess

Bronchiectasis Ankylosing spondylitis Rheumatoid nodules Pulmonary infarction Lung cancer

PRIMARY ASPERGILLOMA

Proliferation of aspergillus in bronchial tree leading to pulmonary cavity

CAUSESInvasive pulmonary aspergillosisChronic necrotizing pulmonary

aspergillosis Allergic bronchopulmonary

aspergillosis

CHEST X-RAY

Solid round mass within the cavity Partially surrounded by radiolucent

crescent-MONOD’S sign Movement of fungal ball in the

cavity Preexisting tuberculous cavities

the most common predisposing condition

CT- SCAN THORAX

Globules of gas are often seen within the interstices of the hyphal mass

CT ANGIOGRAPHYIdentifying hypertrophic

bronchial arteries that supply cystic wall of aspergilloma

SPUTUM CULTURES

Positive in 50% of the cases Not sensitivity and specific PRECIPITATING ANTIBODIES Positive in 95% of the cases

MANAGEMENT OPTIONS

Systemic or local antifungal Surgical resection Bronchial arterial embolization

Conservative management with carefull followup

INTRACAVITARY ANTIFUNGAL AGENTS CT guided percuteaneous

instillation of AMB Endobronchial instillation of

AMB via fiberoptic bronchoscopy

Indication-solitary aspergilloma with severe hemoptysis and contraindication for surgery

ORAL ANTIFUNGAL-ITRACONAZOLE Active against A.fumigatus High tissue penetration into the lung Dose 200-400mg/d for 6-18 months Symptomatic and radiographic

improvement in twothird of patients Major limitations- it works slowly recurrence after

discontinuation not usefull in severe

hemoptysis

SURGICAL RESECTION

Indications severe hemoptysis sarcoidosis chronic immunosuppression increasing titer of specific IgG single large cavity

BRONCHEAL ARTERIAL EMBOLIZATION Management of hemoptysis Only temporarily effective RADIATION THERAPY Indicated in recurrent lifethreatening hemoptysis after BAE

DIFFERENTIAL DIAGNOSIS

Lung cancer Pulmonary abscess wegener’s granulomatosis Bloodclot in a preexisting cavity

Disintegrating hydatid cyst

PREDICTORS OF POOR PROGNOSIS Progressive increase in size Multiple aspergillomas Severe underlying lung disease Immunosuppressive therapy AIDS Sarcoidosis Rising Aspergillus specific IgG Titer Repetitive episodes of severe

hemoptysis

Take home messsage

Aspergilloma-Rare disease BUT NOT VERY RARE

DISEASEImportant firstline D.D for evaluation of hemoptysis

THANK U