Post-Tuberculosis Lung Disease and Aspergilloma
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Direct answer
Post-tuberculosis lung disease is the chronic damage left by treated pulmonary tuberculosis, such as fibrosis, cavities and bronchiectasis. Aspergilloma is a fungus ball that colonises a residual cavity, usually causing haemoptysis, which can be massive. The air-crescent sign and raised Aspergillus-specific IgG support the diagnosis, and chronic pulmonary aspergillosis needs a prolonged azole course.
What you must remember
- Post-TB sequelae: Fibrocavitary disease, bronchiectasis, pleural thickening and destroyed lung, with residual cavities that can be colonised by Aspergillus.
- Aspergilloma: A fungal ball, usually Aspergillus fumigatus, lying within a pre-existing cavity, most often in the upper lobes.
- Air-crescent sign: A crescent of air between the fungal ball and the cavity wall, classic on chest radiograph or CT, though not seen in every case.
- Haemoptysis: The dominant complication, and it can become massive without warning, needing airway protection and bronchial artery embolisation or surgery.
- Serology: Raised Aspergillus-specific IgG supports the diagnosis alongside the radiological lesion.
- Chronic pulmonary aspergillosis: A spectrum including simple aspergilloma and chronic cavitary forms that progress over months, treated with an azole.
- Surgery: Resection is the definitive treatment for massive or recurrent haemoptysis in fit patients, since antifungals alone do not control acute bleeding.
Simple aspergilloma versus progressive disease
Post-tuberculosis damage creates cavities, and a fungal ball forms when one of those cavities is colonised by Aspergillus. The clinical course depends on whether the process stays confined to a single ball or spreads through the lung.
| Feature | Simple aspergilloma | Chronic cavitary aspergillosis |
|---|---|---|
| Lesion | One fungal ball in a pre-existing cavity | Several cavities with surrounding inflammation |
| Course | Often stable for long periods | Progressive over months, with weight loss and fatigue |
| Antifungal role | Limited, as drugs penetrate the ball poorly | Azole, usually itraconazole, for a prolonged course |
| Main concern | Haemoptysis, sometimes massive | Progressive lung destruction |
| Typical management | Observation, with surgery or embolisation for bleeding | Long antifungal course, with surgery in selected cases |
The diagnostic question is therefore whether the lesion is a single ball or a spreading process, since only the spreading forms are primarily treated with long antifungal courses. Haemoptysis needs its own plan in both forms, because bleeding does not respond to antifungal drugs.
Where the exam tries to catch you
Most marks are lost by treating the fungus when the bleeding is the real emergency, or by assuming a culture settles the diagnosis.
- Trap: Calling a sputum culture that grows Aspergillus diagnostic of aspergilloma. Correct: Aspergillus colonises many lungs, so the diagnosis needs the radiological lesion plus supportive serology.
- Trap: Choosing amphotericin B for chronic pulmonary aspergillosis. Correct: Azoles, usually itraconazole, are the usual oral first-line choice, and amphotericin is not the standard first option.
- Trap: Giving prolonged antifungals to a stable simple aspergilloma and expecting regression. Correct: Simple aspergilloma responds poorly to antifungals, so observation with surgery reserved for bleeding is the usual approach.
- Trap: Watching a patient with haemoptysis because the vitals look stable. Correct: Bleeding can turn massive suddenly, so airway protection and embolisation or surgery in fit patients must be planned in advance.
Frequently asked questions
What is the air-crescent sign in aspergilloma?
The air-crescent sign is a crescent-shaped lucency between a fungal ball and the wall of the pre-existing cavity on chest imaging. It is a classic feature of aspergilloma on radiograph or CT, though it is not seen in every case.
Which antifungal is used for chronic pulmonary aspergillosis?
Itraconazole is the usual oral azole for chronic pulmonary aspergillosis, with voriconazole as an alternative. Treatment is prolonged, often lasting months, and is guided by clinical and radiological response.
How is massive haemoptysis from aspergilloma managed?
Massive haemoptysis from aspergilloma is managed first by protecting the airway, then by bronchial artery embolisation, with surgical resection considered in fit patients. Antifungal drugs alone do not control acute bleeding from an aspergilloma.
Does post-tuberculosis lung disease always lead to aspergilloma?
Post-tuberculosis lung disease does not always lead to aspergilloma. Residual cavities are only at risk because Aspergillus can colonise them, and aspergilloma develops in a minority of patients with old cavitary tuberculosis.