Snapshot A 47-year-old man presents to the emergency room with 2 months of fevers, cough, and night sweats. He also reports having hemoptysis. His past medical history of significant for tuberculosis which was adequately treated 2 years ago. He recently tested negative for tuberculosis during routine testing for work which is in the healthcare industry. A chest radiograph shows a cavitary lesion in the left upper lobe. A CT scan further demonstrates a round mobile mass. Fine needle aspiration reveals fungal hyphae along with inflammatory cells. (Aspergilloma) Introduction Classification Aspergillus species Aspergillus fumigatus most commonly causes disease in humans monomorphic fungus with septate hyphae that branch at acute angles (45 degrees) clinical syndromes login to view 10 more bullets found in soil and decomposed material transmission via inhalation of spores Associated conditions hepatocellular carcinoma from aflatoxins that Apsergillus produce Epidemiology Risk factors immunocompromised status neutropenia steroids or cytotoxic drugs hematologic malignancy chronic granulomatous disease asthma pre-existing lung disease ETIOLOGY Pathogenesis in patients with competent immune systems, immune system will clear any Aspergillus spores before it can germinate invasive aspergillosis in immunocompromised patients, spores will germinate and produce invasive hyphal structures ABPA local inflammatory reaction can cause an allergic response Presentation Invasive aspergillosis persistent fever neutropenic patients may present with fever only cough with hemoptysis shortness of breath chest pain Aspergillomas cough with hemoptysis Allergic bronchopulmonary aspergillosis (ABPA) new or worsening cough with hemoptysis shortness of breath brownish black mucus plugs in expectorate asthma exacerbations (wheezing) Imaging Chest radiography indication all patients findings aspergilloma login to view 1 more bullet Chest computed tomography (CT) indication all patients findings invasive aspergillosis login to view 2 more bullets aspergilloma login to view 3 more bullets ABPA login to view 1 more bullet Bronchoscopy indication to obtain sample for culture or pathology invasive aspergillosis findings tracheobronchial ulceration nodules pseudomembranes or plaques Studies Labs detection of Aspergillus galactomannan antigen in serum, bronchoalveolar lavage fluid, or cerebrospinal fluid eosinophilia and elevated IgE in those with ABPA Biopsy of affected tissue hyphae invasion into tissue Culture of sterilely-obtained sample positive culture Making the diagnosis invasive aspergillosis definitive diagnosis of invasive aspergillosis requires either login to view 2 more bullets ABPA based on clinical findings and eosinophilia or elevated IgE aspergilloma abnormal sputum culture or positive culture or serology aspergilloma seen on imaging Differential Pneumocystis pneumonia distinguishing factors hemoptysis is rare often presents as progressive exertional shortness of breath CT imaging shows bilateral and diffuse patchy ground-glass opacities Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) distinguishing factor often involves other organ systems, including skin, cardiac, gastrointestinal, and renal Treatment Medical steroids indications login to view 2 more bullets voriconazole indications login to view 2 more bullets caspofungin indications login to view 2 more bullets amphotericin B indication login to view 2 more bullets Operative surgical resection indication login to view 1 more bullet Complications Disseminated infection Vascular invasion Prognosis Invasive aspergillosis can have high mortality (> 60%) in severely immunocompromised patients