A 65-year-old man comes to the emergency department due to an episode of hemoptysis that occurred earlier this morning. The patient estimates that he coughed up about 100 mL of blood. Prior to this episode he was in his usual state of health and felt well, with no fevers, night sweats, or weight loss. He has had occasional episodes of blood-tinged sputum over the past few months. The patient's past medical history is significant for tuberculosis (TB) that was effectively treated several years ago. He had smoked a pack of cigarettes daily for 45 years but quit 4 years ago. A representative cut of the CT scan, shown in the image below, demonstrates changes consistent with prior TB infection, including an old left upper lobe cavity. Compared to prior scans, the main difference is that the cavity now appears to be filled with a round mass. Which of the following best describes this patient's condition?

Question

A 65-year-old man comes to the emergency department due to an episode of hemoptysis that occurred earlier this morning.  The patient estimates that he coughed up about 100 mL of blood.  Prior to this episode he was in his usual state of health and felt well, with no fevers, night sweats, or weight loss.  He has had occasional episodes of blood-tinged sputum over the past few months.  The patient's past medical history is significant for tuberculosis (TB) that was effectively treated several years ago.  He had smoked a pack of cigarettes daily for 45 years but quit 4 years ago.  A representative cut of the CT scan, shown in the image below, demonstrates changes consistent with prior TB infection, including an old left upper lobe cavity.  Compared to prior scans, the main difference is that the cavity now appears to be filled with a round mass.  Which of the following best describes this patient's condition?

Quizplus · Accepted Answer

11ec160b_388c_425a_9249_333603bdb536_MD0001_00 Aspergillus fumigatus is a mold that is widely present in organic matter. It forms septate hyphae that branch at 45-degree angles (V-shaped branching). The spores are inhaled with the air and are typically cleared by the mucus and ciliated epithelium of the respiratory tract. In individuals with suppressed immune defenses, Aspergillus causes a wide spectrum of diseases. This patient likely has hemoptysis due to an aspergilloma (mycetoma), which represents Aspergillus colonization. Aspergillomas develop in old lung cavities (from tuberculosis, emphysema, sarcoidosis). Aspergillus colonizes the cavity, forming a "fungus ball" (seen in the left upper lobe on this patient's CT) without lung tissue invasion. Classically, an aspergilloma will appear on chest x-ray as a radiopaque structure that shifts when the patient changes position. This condition may be asymptomatic or it may cause cough and hemoptysis. (Choice A) Allergic bronchopulmonary aspergillosis (ABPA) occurs in patients with asthma. It presents with wheezing and migratory pulmonary infiltrates. Increased titers of IgE and antibodies to Aspergillus are diagnostic of ABPA. (Choice C) Aspergillomas are not contagious. This cavity is unlikely to represent recurrent tuberculosis (no fevers, night sweats, weight loss). (Choice D) Invasive pulmonary aspergillosis occurs in severely immunosuppressed and neutropenic patients and is characterized by primary lung involvement with cough, hemoptysis, pleuritic chest pain, and fever. Necrotizing pneumonia and granuloma formation also occur. Extrapulmonary involvement is common. (Choice E) Although it could cause hemoptysis, a malignant lesion would not typically develop as a circumscribed round mass within an old cavity and is a less likely diagnosis in this patient who has felt well with no weight loss recently. Educational objective: Aspergillus fumigatus causes a wide spectrum of disease. It can be an opportunistic infection in immunosuppressed and neutropenic patients (invasive pulmonary aspergillosis). Aspergillosis can be colonizing (aspergilloma) when it forms a fungus ball within a preexisting lung cavity. It can also cause a lung hypersensitivity reaction in allergic bronchopulmonary aspergillosis in individuals with asthma.

A 65-Year-Old Man Comes to the Emergency Department Due to an Episode