A 72-year-old man presents with a chronic cough. This has been getting gradually worse for the past 3 months. On around five occasions he has coughed up some blood stained sputum. His past medical history includes ischaemic heart disease (NSTEMI 4 years ago), spinal stenosis and tuberculosis (treated 50 years ago). He drinks 20 units of alcohol per week and has a 55 pack-year history of smoking.
On examination scattered crackles are noted in both lung fields, but are more prominent on the left.
A chest x-ray is requested:
What is the most likely underlying diagnosis?
Aspergilloma
Reactivated tuberculosis
Lung cancer
Histoplasmosis
Lung abscess
The chest x-ray shows a cavity (secondary to old tuberculosis) in the left upper zone containing an aspergilloma. Please see below for an annotated close-up image with an accompanying CT scan from the same patient.
Aspergilloma
An aspergilloma is a mycetoma (mass-like fungus ball) which often colonises an existing lung cavity (e.g. secondary to tuberculosis, lung cancer or cystic fibrosis)
Usually asymptomatic but features may include
cough
haemoptysis (may be severe)
Investigations
chest x-ray containing a rounded opacity
high titres Aspergillus precipitins
