Aspergilloma Presenting as Endobronchial Mass

A 40-year-old man with a history of pulmonary tuberculosis during childhood in Congo, presented to the emergency department for hemoptysis. He reported mild hemoptysis for years, which had significantly worsened over the past week. The patient had no significant past medical history other than childhood pulmonary tuberculosis. He was immunocompetent with no history of diabetes, human immunodeficiency virus infection, malignancy, or immunosuppressive treatment. He had no history of smoking.

Blood laboratory investigations were normal with no biological inflammatory syndrome (white blood cell count, 4.37 g/L; C-reactive protein, 3 mg/L). Pulmonary computed tomography revealed tuberculosis sequelae in the right upper lobe with surrounding consolidation (Figure 1A). Flexible bronchoscopy revealed obstruction of the apical segmental bronchus (B1) of the right upper lobe by a yellowish, friable soft-tissue mass with a granular aspect, increased vascularity, and mild active bleeding (Figure 1B). Bronchoscopy biopsy was not performed to avoid worsening the observed bleeding. Instead, bronchoalveolar lavage (BAL) was undertaken, providing comprehensive diagnostic information: bacteriological analysis was negative, mycobacteriological analysis was negative, mycological culture revealed one colony formation unit of Aspergillus fumigatus , BAL Aspergillus antigen was strongly positive (enzyme-linked immunosorbent assay [ELISA] Platelia Aspergillus Bio-Rad [Hercules, CA, USA] on Evolis automate, threshold: 0.5), and direct examination showed an absence of suspicious cells but the presence of mycelial filaments on Grocott- Gomori’s methenamine silver staining. Serum Aspergillus-specific immunoglobulin G (IgG) antibodies were strongly positive at 55 AU/mL (ELISA anti-Aspergillus IgG Bio-Rad; normal <10 AU/mL).

Fig. 1.

(A) Pulmonary computed tomography showing tuberculosis sequelae in the right upper lobe with surrounding consolidation. (B) Flexible bronchoscopy identifying an obstructing soft-tissue mass in the apical segmental bronchus (B1) of the right upper lobe with mild active bleeding. (C) Histopathological analysis showing a dilated bronchial cavity containing fragmented fungal material (‘fungus ball’; hematoxylin, eosin and saffron staining, low magnification, scale bar=3 mm). (D) Y-shaped, branching septate hyphae with a high affinity for Grocott-Gomori’s Methenamine Silver staining (high magnification, optical zoom ×400, scale bar=50 μm).

The diagnosis of endobronchial aspergillosis (EBA) was made by integrating the clinical, bronchoscopic, laboratory, and radiological parameters. Given that antifungal drug susceptibility testing was not available, itraconazole (400 mg daily) was initiated based on local guidelines. Therapeutic drug monitoring was performed; no dosage adjustment was required. The patient was referred from the time of diagnosis to the surgical team to avoid hemoptysis recurrence. Treatment was continued for 1 month until the surgery, without recurrence of major hemoptysis.

The patient underwent a right upper lobectomy without any complication. Histopathological analysis confirmed an EBA, showing a dilated bronchial cavity containing fragmented fungal material (‘fungus ball’) (Figure 1C), highlighted by distinctive Y-shaped, branching septate hyphae with a high affinity for Grocott-Gomori’s methenamine silver staining (Figure 1D). No vascular involvement was found. Antifungal therapy by itraconazole was resumed after the surgery for 1 month. To date, after 6 months of clinical follow-up, hemoptysis has not recurred.

EBA is a rare form of chronic pulmonary aspergillosis characterized by the endoluminal fungal growth in structurally damaged lungs, most commonly following tuberculosis or lung cancer [1-4]. A review of 28 published cases identified hemoptysis and cough as the most frequent symptoms, occurring in 57.1% of patients [3]. The bronchoscopic appearance of EBA can vary, making visual diagnosis challenging [5-7].

EBA-related hemoptysis can be life-threatening [3,8,9] and clinicians should be aware of this entity to ensure timely diagnosis and management. Although no standardized treatment protocol exists, a combination of antifungals and resection (either surgically or by bronchoscopy) is usally proposed [1,2,4,10-12]. This case highlights the importance of suspecting EBA during bronchoscopy in patients with hemoptysis and damaged lungs as the variable bronchoscopic presentations can be misleading. Misdiagnosis or empiric antibiotic therapy can delay appropriate treatment, leading to fatal hemoptysis.