What are Aspergillomas?

Aspergillomas are mass-like fungus balls that are typically composed of Aspergillus fumigatus and are non-invasive or colonizing form of pulmonary aspergillosis. It usually falls under the subgroup chronic pulmonary aspergillosis.

Aspergillomas occur in patients with normal immunity with structurally abnormal lungs which leave behind
cavities in the lungs. The fungus thus colonises pre-existing cavities. 

Conditions which can form cavities in the lung are many and include tuberculosis (commonest), sarcoidosis,
bronchiectasis due to any cause, bronchogenic cysts, air filled cavities (also called pneumatoceles) caused by
infections like pneumocystis or even Covid infections.

Most aspergillomas are asymptomatic. Occasionally due to surrounding new blood vessel formation and
inflammation, patients can cough up blood. This is called hemoptysis and may very from minor streaks of
bleeding to life threatening quantities. The real risk to life arises because large quantity of blood can flood both
lungs, preventing oxygenation and is in effect, like what happens in drowning.

Aspergillomas typically occur in the cavities after lung tuberculosis, even if it has been treated successfully.
Therefore, they are most frequently found in the upper lobes though they can rarely involve the lower lobes.
An aspergilloma can be seen as a mass within a cavity on a plain xray chest. The mass is typically spherical
or ovoid. The air around the aspergilloma takes a crescentic shape. On different positioning of the patient, the
mass can be shown to be mobile. 

CT better demonstrates the plain radiographic findings of a rounded mass within a cavity. The air crescent
sign around the mass is usually present, and the mobility of the mass can be demonstrated between prone and
supine positioning


Due to the inflammation and vascular granulation tissue formation, the bronchial arteries supplying the wall of the cavity can be enlarged and are seen well in a CT arteriogram. The adjacent pleura may also be thickened.

An asymptomatic aspergilloma does not necessarily require treatment, and the cavity is essentially isolated from any systemic administration of antifungal so antifungals are rarely useful and are not recommended .

In the setting of brisk hemoptysis, angiography may be performed on an emergency basis and selective blockage of the feeding vessel (called bronchial artery embolization or BAE) can be life-saving. Failing this, or in cases of repeated hemoptysis, surgical excision with a lobectomy remains the gold standard .

The mortality rate varies widely and used to be high, but in more recent series is incidence of problems is very low, even were requiring surgery. 

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