What is Causing This Man’s Hemoptysis?

History

A 42-year-old male comes to your office after a bout of hemoptysis 2 days prior that he said was “concerning.” He has previously been treated for asthma and has done well over the last 3 years, however, recently he has been experiencing progression of his asthma symptoms. 

Physical Examination

The patient appears well-nourished and in no acute distress. Vital signs reveal mild fever and mild tachycardia. His oxygen saturation and blood pressure are within normal limits. The respiratory rate is slightly elevated. 

Auscultation of the chest reveals mild-to-moderate diffuse wheezing. The physical exam is otherwise unrevealing. You order 2 views of the chest in further investigation (Figures 1 and 2).

Figure 1. A frontal upright radiograph of the chest demonstrates cylindrical soft tissue densities projecting from the pulmonary hila laterally, bilaterally in the right and left upper and lower lung zones.

Figure 2. A laterl upright radiograph of the chest demonstrates cylindrical soft tissue densities projecting from the pulmonary hila laterally, bilaterally in the right and left upper and lower lung zones.

Laboratory Tests

Frontal and lateral upright radiographs of the chest reveal longitudinal areas of increased density in the right upper lobe, right lung base, left upper, and left lobe lung base with a question of air space disease at the right lung base observed on the frontal projection. There is no evidence of pleural effusions. 

No evidence of mediastinal adenopathy is observed. The trachea is patent. The cardiac silhouette is within normal limits in size. The abdominal bowel gas pattern is unremarkable. No evidence of pulmonary edema is seen.

What do the conventional radiographs of the chest suggest?

A. Atelectasis
B. Bronchogenic pneumonia
C. Allergic bronchopulmonary aspergillosis
D. Metastatic disease
E. Interstitial lung disease

Answer: Allergic bronchopulmonary aspergillosis

On Figures 1 and 2, it is difficult to exclude a small mass in the lungs. Given the patient history of hemoptysis and his concern, a chest CT was ordered (Figures 3-5).

Axial images reveal distended bronchi that are mucus filled, diffusely consistent with mucus plugs. There is no significant air space disease. No definite masses are identified. The tracheobronchial tree is patent proximally. Again, there is no adenopathy. 

The CT appearance is classic for allergic bronchopulmonary aspergillosis.

In retrospect, the longitudinal areas of increased density on the chest radiographs represent distended bronchi that are filled with mucus/fungus. This is the classic “fingered glove” appearance seen in allergic bronchopulmonary aspergillosis. Again, this is confirmed on the CT scan.

Figure 3. An axial CT image just below the level of the carina demonstrates distended mucous impacted bronchi in the right middle lobe and left lower lobe.

Figure 4. An axial CT image through the level of the middle third of the left ventricle demonstrates distended mucous impacted bronchi in the right lower lobe and lingula on the left.

Discussion

Allergic bronchopulmonary aspergillosis typically occurs in patients with preexisting asthma, and those patients with cystic fibrosis. Chest radiographs may reveal pulmonary infiltrates in addition to distended/mucus filled bronchi. Patients can also present with fever and a cough mimicking pneumonia. Typically, this pneumonia is unresponsive to conventional antibacterial therapy. 

Physical exam demonstrates wheezing upon auscultation of the chest. The patient is often coughing up mucus and short of breath. 

Allergic bronchopulmonary aspergillosis represents a hypersensitivity to the fungus Aspergillus. There is inflammation in the airways, which contributes to expansion of bronchi/bronchiectasis. The allergic response does raise the eosinophil count and blood levels of IgE—which are helpful complementary diagnostic tests in the setting of allergic bronchopulmonary aspergillosis. Sputum staining and sputum culture can often be helpful. Skin testing for sensitivity to aspergillosis is helpful in demonstrating sensitivity.

Figure 5. A coronal reconstruction CT image through the middle third of the chest anterioposteriorly demonstrates distended mucous impacted bronchi in the right upper lobe, right middle lobe, left upper lobe and left lower lobe.

Treatment

Treatment consists of steroid therapy to reduce inflammation and antifungal medication.

William Yaakob, MD, is a board-certified radiologist working in Tallahassee, FL.