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Aspergilloma: Introduction

An aspergilloma, commonly called a fungal ball, is a clump of fungus (Aspergillus fumigatus) that develops inside a pre-existing cavity in the lung. These cavities often result from diseases like tuberculosis (TB), sarcoidosis, bronchiectasis, or old lung abscesses.

While aspergilloma itself does not always invade healthy lung tissue, its presence can lead to severe complications such as massive hemoptysis (coughing blood), making early diagnosis and timely treatment essential.

What Causes Aspergilloma?

Aspergillomas occur when fungal spores of Aspergillus settle and grow inside lung cavities. Over time, these spores form a tangled ball of fungal filaments, mucus, inflammatory cells, and tissue debris.

Predisposing factors include:
  • History of Pulmonary Tuberculosis (TB): Post-TB cavities are the most common sites.
  • Bronchiectasis:Abnormally widened airways create pockets for fungal colonization.
  • Sarcoidosis and Fibrotic Lung Diseases: Structural lung damage predisposes to cavity formation.
  • Lung Abscesses: Old healed abscesses may leave residual cavities.
  • Weakened Immunity: Long-term steroid therapy, chemotherapy, or chronic illnesses.
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Symptoms of Aspergilloma

Symptoms vary depending on the size of the fungal ball, location, and whether bleeding occurs.

Common symptoms include:

  • Hemoptysis (Coughing up Blood):
    • The hallmark and most feared symptom.
    • Can range from streaks of blood in sputum to life-threatening massive bleeding.
  • Chronic Cough: Often productive, sometimes with foul-smelling sputum.
  • Breathlessness: Especially in patients with already reduced lung reserve.
  • Chest Pain or Tightness
  • Fatigue, Weight Loss, and General Weakness

Importantly, some patients may remain asymptomatic until a major episode of hemoptysis occurs, making regular follow-up critical.

Why Does Aspergilloma Cause Hemoptysis?

The fungal ball lies freely within the cavity but can irritate and erode the thin-walled blood vessels around it. Over time, these vessels (particularly branches of the bronchial arteries) become inflamed and fragile.

When they rupture, patients experience coughing blood. In severe cases, bleeding can be massive and life-threatening, leading to suffocation, aspiration, or shock.

This is why any patient with aspergilloma and hemoptysis needs urgent evaluation by a thoracic surgeon.


Diagnosis of Aspergilloma

Diagnosis is usually made through a combination of clinical history, imaging, and microbiological studies.

  • Chest X-ray: May show a “fungal ball” within a cavity, sometimes with an air crescent sign.
  • CT Scan of the Chest: Gold standard for diagnosis. Clearly shows the fungal mass, its relation to surrounding structures, and suitability for surgery.
  • Sputum Culture or Serology: Detects Aspergillus species.
  • Bronchoscopy: Sometimes used for evaluation, though bleeding risk must be considered.

Treatment of Aspergilloma

  1. Medical Therapy
    • Antifungal Medications (Itraconazole, Voriconazole, Amphotericin B) are sometimes prescribed.
    • However, in a well-formed aspergilloma, drugs usually cannot penetrate the fungal ball and therefore do not cure the disease.
    • Best reserved for patients who are unfit for surgery or have disseminated aspergillosis.
  2. Bronchial Artery Embolization (BAE)
    • An interventional radiology procedure where bleeding vessels are selectively blocked.
    • Provides rapid control in emergencies and can save lives during massive hemoptysis.
    • Limitations:
      • Temporary measure, not a cure.
      • Recurrence rates are high (40–60%).
      • Requires specialized centers and may need to be repeated.
  3. Surgical Treatment – The Definitive Cure

    Surgery is the gold standard for treating localized aspergilloma, especially when hemoptysis is present. By removing the part of the lung containing the fungal ball, the source of bleeding is eliminated permanently.

    When Should Surgery Be Considered?

    • Recurrent or Massive Hemoptysis
    • Localized Aspergilloma confined to one lobe or segment
    • Failed BAE or Medical Therapy
    • Good Overall Health and Lung Function allowing surgery

    Patients with poor lung reserve or multiple cavities may not be suitable surgical candidates and may require individualized management.

    How Surgery Helps in Localized Aspergilloma

    • Removes the fungal ball and diseased cavity entirely
    • Prevents recurrence of bleeding
    • Improves quality of life by eliminating chronic cough and infection
    • Provides a definitive cure, unlike medical or interventional options

    Surgery vs. BAE– Why Surgery is Superior

    Aspect Surgery BAE
    Control of Bleeding Permanent Temporary
    Recurrence Rate Very Low High (40–60%)
    Definitive Cure Yes No
    Suitability For localized disease in fit patients Emergency/poor surgical candidates

    Thus, surgery remains the best option in patients who can safely undergo it.

    Surgical Modalities for Aspergilloma

    1. Video-Assisted Thoracoscopic Surgery (VATS)
      • Minimally invasive “keyhole” surgery using a camera and instruments through 2–3 small incisions.
      • Advantages:
        • Less pain
        • Faster recovery
        • Shorter hospital stay
        • Smaller scars
    2. Robotic Thoracic Surgery
      • Advanced technique using robotic arms and 3D vision.
      • Greater precision and flexibility than VATS.
      • Especially beneficial in complex cases with dense adhesions around the fungal ball.
    3. Open Thoracotomy
      • Traditional approach with a larger incision.
      • Still required for very large, complex, or multiple aspergillomas.

    Prognosis After Surgery

    With proper patient selection, surgical outcomes are excellent. Most patients experience:

    • Complete resolution of hemoptysis
    • Improved quality of life
    • Low recurrence rates

    Mortality and complication rates are higher than for some other lung surgeries due to adhesions and fragile vessels, but in experienced centers, surgery remains safe and highly effective.

    Key Takeaways

    • Aspergilloma is a serious lung condition, often arising in cavities after tuberculosis or chronic lung disease.
    • Hemoptysis is the most dangerous symptom and requires urgent attention.
    • While antifungal drugs and BAE may help in some cases, surgery is the only definitive cure for localized aspergilloma.
    • Modern minimally invasive techniques like VATS and robotic surgery allow faster recovery with excellent long-term outcomes.

    If you or your loved one has been diagnosed with Aspergilloma or are experiencing coughing of blood, seek expert evaluation immediately. Dr. Belal Bin Asaf specializes in advanced thoracic surgery, including minimally invasive and robotic procedures for aspergilloma, ensuring safe and effective treatment.

    Book an Appointment Today

Frequently Asked Questions (FAQs) about Aspergilloma

  • Aspergilloma is a fungal ball that develops inside a lung cavity, usually after tuberculosis or another chronic lung disease.
  • Aspergillosis refers to a broader spectrum of Aspergillus-related lung diseases, which can include allergic bronchopulmonary aspergillosis (ABPA), chronic pulmonary aspergillosis (CPA), and invasive aspergillosis.

No. Aspergilloma is not cancer. It is a fungal infection confined to a lung cavity. However, its symptoms such as coughing blood (hemoptysis) may mimic those seen in lung cancer.

No. Once a fungal ball forms, it does not disappear spontaneously. In fact, it can enlarge over time and cause dangerous bleeding. Treatment is essential, especially if symptoms develop.

The most common and dangerous symptom is hemoptysis (coughing blood). Other symptoms include chronic cough, chest discomfort, and fatigue.

Antifungal medicines like Itraconazole or Voriconazole are sometimes used, but they are not effective for curing a well-formed aspergilloma because drugs cannot penetrate the fungal ball. Surgery is the definitive treatment in suitable patients.

BAE is a minimally invasive procedure where bleeding blood vessels are blocked to stop hemoptysis. It is useful in emergencies but does not cure aspergilloma. Bleeding often recurs unless the fungal ball is surgically removed.

Surgery is advised when:
  • The patient has recurrent or massive hemoptysis
  • The aspergilloma is localized to one lung area
  • Medical therapy or BAE has failed
  • The patient has enough lung function to tolerate surgery

  • Video-Assisted Thoracoscopic Surgery (VATS): Minimally invasive, faster recovery, less pain.
  • Robotic-Assisted Thoracic Surgery: High precision, especially useful in complex cases.
  • Open Thoracotomy: Required for large or complicated aspergillomas

Most patients spend 5–7 days in hospital after surgery. Recovery is faster with minimally invasive techniques like VATS or robotic surgery. Long-term, patients experience significant improvement in symptoms and resolution of hemoptysis.

If the aspergilloma is completely removed, recurrence is very rare. However, patients with underlying lung disease remain at risk for other complications and need regular follow-up.

If untreated, aspergilloma can lead to:
  • Recurrent or massive life-threatening hemoptysis
  • Chronic lung infections
  • Severe decline in quality of life

Aspergilloma surgery can be technically challenging because of dense adhesions and fragile blood vessels. However, in experienced thoracic surgery centers, surgical success rates are high with excellent long-term outcomes.

Still have questions about Aspergilloma and its treatment? Book a consultation with Dr. Belal Bin Asaf, one of India’s leading thoracic surgeons, for expert advice and personalized care.

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