A 42-year old woman who underwent a left thoracotomy for a mediastinal lesion of unknown pathology 20 years ago, was referred to our medical center with one day of mild hemoptysis. She had neither chest pain nor shortness of breath. She was diagnosed with a simple aspergilloma on radiologic imaging few years ago and has been having an episodic productive cough for which multiple courses of antibiotics were prescribed. She also had a similar episode of mild hemoptysis one and a half year prior, which self-resolved. The patient was afebrile, appeared comfortable and was hemodynamically stable. Chest auscultation was unremarkable. A chest radiograph showed a retro-cardiac opacity. An enhanced computed tomography (CT) of the thorax showed a left lower lobe fungus ball with a meniscus sign, consistent with a simple aspergilloma (Fig. 1). These findings were unchanged when compared to previous scans.
A flexible bronchoscopy was performed and revealed a small amount of blood oozing from the left lower lobe with no visible endobronchial lesions. Cytology on bronchoalveolar lavage taken from that lobe showed benign bronchial cells and few red blood cells. Respiratory cultures grew 60,000 colonies of pan-susceptible Pseudomonas aeruginosa and were negative for tuberculosis. IgG and precipitins against Aspergillus were also negative. In view of her presumed diagnosis of aspergilloma coupled with recurrent hemoptysis, the patient underwent wedge resection of the left lower lobe lesion. Examination of the specimen showed a white gauze impacted within a dilated bronchus, with peribronchial fibrosis, inflammation and hemorrhage (Fig. 2).
Transverse section of a thoracic CT-scan showing what appears to be a "fungus ball" within a cavity in the anterior aspect of the lateral bronchopulmonary segment of the left lower lobe.