대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Subacute invasive pulmonary aspergillosis.

Radiologic Findings

Figure 1.Chest PA shows clustered cystic bronchiectasis or cavities in BULs and Rt. Hilar area with air-fluid levels.
Figure 2.. Chest CT demonstrates multifocal clustered or discrete cyst/cavitations with irregular wall thickening and internal fluid collection in the entire lung. Also, there is peribronchial consolidation and GGO in LLL posterior basal segment and multiple enlarged punctated calcifed enlarged LNs in Rt. paratracheal and subcarinal areas.
Figure 3. 10months later, FU chest PA shows markedly regression of multifocal clustered cyst/cavitations and consolidation in Rt. hilum and BULs, but remained irregular consolidation/GGO in LUL.

Brief Review

After hospitalization, the patient was disagnosed with HIV(+), AFB(-), TB PCR(-), galactomannan (+) through bronchoscopic aloveolar lavage and improved with the use of voriconazol and prophylactic antibiotics.
Aspergillus is a ubiquitous fungus whose clinical manifestations and prognosis after infection depend on the host's immune status. Subacute invasive pulmonary aspergillosis (SIPA) is a progressive fungal infection caused by Aspergillus spp. that primarily affects patients with mild to moderate immunosuppression. Unlike invasive pulmonary aspergillosis (IPA), which occurs in severely immunocompromised individuals, SIPA develops more insidiously and presents with overlapping features of invasive and chronic pulmonary aspergillosis(CPA). Common risk factors include corticosteroid therapy, structural lung disease, and conditions such as diabetes or chronic infections like tuberculosis (PTB)​. Radiologically, it typically manifests as consolidations that progressively cavitate over time, often accompanied by pleural thickening, effusion, or pyothorax. Cavities may enlarge and merge, sometimes forming an aspergilloma—a dense fungal ball within the cavity​. In contrast to chronic cavitary pulmonary aspergillosis (CCPA), which evolves in pre-existing lung cavities, SIPA begins as infiltrative lung lesions that cavitate as the disease advances​. Ground-glass opacities, centrilobular nodules, and tree-in-bud patterns have also been observed, reflecting airway involvement​. CPA is presented usually as one or more cavities, typically with an irregular or thick wall, that tend to become larger over years, commonly forming pericavitary infiltrates and perforating into the pleura. These cavities tend to affect the upper lobes and they may or may not contain aspergilloma. One of the previous studies showed that the most common imaging manifestations in CPA include cavitation (63.9%), fungal ball (36.7%), pleural thickening (32.0%), and bronchiectasis (31.3%). Clinically, SIPA presents with nonspecific symptoms, including chronic cough, hemoptysis, chest pain, and fever, making early diagnosis challenging. Diagnosis relies on imaging findings, histopathology confirming parenchymal invasion by fungal hyphae, and adjunctive tests such as bronchoalveolar lavage (BAL), galactomannan assay, and fungal cultures​. Given its intermediate position between IPA and chronic pulmonary aspergillosis, SIPA highlights the importance of timely clinical suspicion, particularly in at-risk populations, and the role of imaging in guiding diagnosis and management.

References

1. Alexander BD, Lamoth F, Heussel CP, Prokop CS, Desai SR, Morrissey CO, Baddley JW. Guidance on Imaging for Invasive Pulmonary Aspergillosis and Mucormycosis: From the Imaging Working Group for the Revision and Update of the Consensus Definitions of Fungal Disease from the EORTC/MSGERC. Clin Infect Dis. 2021 Mar 12;72(Suppl 2):S79-S88. doi: 10.1093/cid/ciaa1855. PMID: 33709131.
2. Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Thorax. 2015 Mar;70(3):270-7. doi: 10.1136/thoraxjnl-2014-206291. Epub 2014 Oct 29. PMID: 25354514.
3. Kousha M, Tadi R, Soubani AO. Pulmonary aspergillosis: a clinical review. Eur Respir Rev. 2011;20(121):156-74.

Keywords