Imaging Spectrum in Chronic Pulmonary Aspergillosis

Abstract

Chronic pulmonary aspergillosis (CPA) is a life-threatening respiratory fungal infection that is almost exclusively seen in patients with preexisting structural lung disease with no or mild immunosuppression. The clinical presentation and imaging findings are varied and often pose a diagnostic challenge; and the disease is often present for a long time before being correctly diagnosed. High-resolution chest computed tomography is the imaging modality of choice because it helps identify various forms of CPA, which can range from a simple aspergilloma and chronic cavitary form, to the subacute invasive and end-stage fibrotic form. The knowledge of the imaging features of this disease cannot be overemphasized because it can assist the clinician in reaching at an early diagnosis and timely initiation of appropriate antifungal therapy, thereby improving patient management and treatment outcome. Moreover, imaging also plays a pivotal role during follow-up in patients of CPA to assess the treatment response. In the current review, we present an illustrative review of radiologic patterns seen in various forms of CPA.

Figure 1.

Simple aspergilloma. Axial high-resolution computed tomography sections in 38-year-old male with post–primary tuberculosis. (A) Supine and (B) prone images showing mobile intracavitary contents (simple aspergilloma) in the left lower lobe.

Figure 2.

Chronic cavitary pulmonary aspergillosis. Axial high-resolution computed tomography sections of a 36-year-old male patient, a known case of chronic obstructive pulmonary disease who presented with chronic fatigue, breathlessness, and weight loss, shows parenchymal destruction of the right upper lobe with residual cavitary and bronchiectatic changes (red arrows). A cavity containing intraluminal simple aspergilloma is also seen (black arrow) in panel A.

Figure 3.

Subacute invasive aspergillosis. Axial contrast-enhanced computed tomography sections (mediastinal window) in a 20-year-old woman who was on chronic low-dose steroids and presented with fever and exacerbation of shortness of breath; showed multiple peripherally enhancing cavities with internal necrosis and presence of intra-cavitary air-fluid levels (red arrows).

Figure 4.

Chronic fibrosing pulmonary aspergillosis. Axial high-resolution computed tomography section in a 66-year-old woman with weight loss, hemoptysis, and chronic shortness of breath showing extensive fibrotic destruction of the left lung field with volume loss and ipsilateral mediastinal shift (red arrow).

Figure 5.

Flowchart denoting a proposed imaging algorithm in a case of suspected chronic pulmonary aspergillosis.