Controversies in the clinical management of chronic pulmonary aspergillosis

Abstract

Chronic pulmonary aspergillosis has a range of manifestations from indolent nodules to semi-invasive infection. Patients may be asymptomatic or have chronic symptoms such as cough and weight loss or present with life-threatening haemoptysis. The physician can choose from a range of available therapies including medical therapy with antifungals, minimally invasive therapy with intracavitary antifungal therapy and surgery involving open thoracotomy or video-assisted thoracoscopic surgery. The patients with the most severe forms of pulmonary infection may not be surgical candidates due to their underlying pulmonary condition. The management of haemoptysis can include tranexamic acid, bronchial artery embolisation, antifungals or surgery. There are few controlled studies to inform clinicians managing complex cases, so a multidisciplinary approach may be helpful.

FIGURE 1

Computed tomography (CT) of the chest (clinical scenario 1). a) CT chest in 2014, showing the residual right upper lobe cavity following completion of tuberculosis treatment. b) CT chest in 2017, showing interval development of a soft tissue density within the pre-existing right upper lobe cavity. c) CT chest in 2021, showing interval enlargement of the right upper lobe cavity and soft tissue density. d) CT chest in 2023, showing a partial response with reduction in soft tissue density after 18 months of therapy with oral itraconazole.

FIGURE 2

Computed tomography (CT) of the chest in 2014 (clinical scenario 2). a) The coronal view reveals a thick-walled cavity at the left apex, left upper lobe fibrosis and retraction. b) The axial view reveals debris in the left apical cavity, with adjacent peribronchial thickening.

FIGURE 3

a) Computed tomography (CT) of the chest in 2020, the axial view shows progressive destruction of lung in the left apex with a fungus ball in a large cavity. b) CT of the chest in 2023, the coronal view shows progressive destruction of the left upper lobe, pleural thickening and bronchiectasis.