Diagnosis and management of simple aspergilloma

The term "simple aspergilloma" is used in patients who have only one aspergilloma that is stable on imaging obtained at least three months apart. It is often termed a "fungus ball" or "mycetoma" by radiologists. Patients are typically asymptomatic, although hemoptysis can occur, including severe hemoptysis in a small subset of patients. Our approach to simple aspergillomas is based on our clinical experience; clinical judgement is advised, and referral to specialists is recommended for complex patients. Patients who have significant symptoms other than hemoptysis (eg, worsening cough, shortness of breath) that are not attributable to underlying lung disease are typically diagnosed with, and managed as, CCPA instead of simple aspergilloma (refer to UpToDate content for details).

BAE: bronchial artery embolization; CCPA: chronic cavitary pulmonary aspergillosis; CT: computed tomography.

* Severe immunocompromising conditions include neutropenia, use of medications that chronically suppress cellular immune response (eg, transplant recipients, high-dose corticosteroids [eg, ≥ equivalent of prednisone 0.3 mg/kg/day for >3 weeks]), and graft-versus-host disease, among other conditions.

¶ As an adjunct to surgery or BAE, we often give tranexamic acid to patients with severe hemoptysis until the hemoptysis resolves. However, the agent is not universally used for this purpose. Refer to UpToDate content for details.

Δ Prior to surgery, we advise surgeons to obtain intraoperative fungal, bacterial, and mycobacterial cultures and susceptibility testing. We also advise them to administer 2% taurolidine into the pleural space during surgery if intraoperative spillage occurs.

◊ Antifungal options are outlined in UpToDate content.

§ If surgery is imminent or there is concern for azole resistance, give an echinocandin on the day of surgery.

¥ BAE can act as definitive treatment for hemoptysis or as a temporizing measure while awaiting surgery. We typically do not provide pre-procedure or post-procedure antifungals for patients receiving BAE. For patients receiving intravenous amphotericin B, we withhold amphotericin doses for 24 to 48 hours after BAE to avoid additive renal toxicity.

‡ Some experts treat hemoptysis with installation of antifungals into the aspergilloma cavity. Data are scarce for this practice. We do not advise this intervention except in select patients at institutions with extensive experience performing the procedure.

† Hyphae are expected to be visualized in specimens from inside the cavity or the fungus ball but not in the lung tissue itself.

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Diagnosis and management of simple aspergilloma