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 invasive aspergillosis invasive infection of the lung seen in neutropenic and other immunocompromised patients aspergilloma mycetoma (“fungal ball”) in pre-existing cavity non-invasive allergic bronchopulmonary aspergillosis (ABPA) hypersensitivity reaction in patients with cystic fibrosis or asthma causes bronchiectasis and eosinophilia non-invasive 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 round or ovoid mass, often mobile Chest computed tomography (CT) indication all patients findings invasive aspergillosis nodules with halo sign (rim of ground glass opacity) cavitary lesions aspergilloma well-formed cavitary lesion, often mobile (changes as the patient changes position) Monad sign air surrounding soft tissue mass, indicating pre-existing cavity ABPA bronchiectasis 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 pathologic examination with invasive hyphae in tissue positive Aspergillus culture 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 first-line ABPA voriconazole indications first-line invasive aspergillosis caspofungin indications contraindication to voriconazole invasive aspergillosis amphotericin B indication often used as adjuvant therapy with voriconazole invasive apsergillosis Operative surgical resection indication aspergilloma Complications Disseminated infection Vascular invasion Prognosis Invasive aspergillosis can have high mortality (> 60%) in severely immunocompromised patients