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Singular Observation of a Desirable Change After Bronchial Artery Published online: 2021-07-27 INTERVENTION RADIOLOGY & VASCULAR Singular observation of a desirable change after bronchial artery embolization for hemoptysis in intracavitary aspergilloma B P K Prasad, Brijesh Ray1 Department of Interventional Radiology, Rajagiri Hospital, 1Department of Imaging and Interventional Radiology, Aster Medcity Hospital, Kochi, Kerala, India Correspondence: Dr. B P K Prasad, Department of Interventional Radiology, Rajagiri Hospital, Aluva Munnaar Road, Chunangamvely, Aluva, Kochi ‑ 683 112, Kerala, India. E‑mail: [email protected] Abstract Aspergillomas are fungal balls developing in pre‑existing lung cavities, which are most commonly secondary to tuberculosis. Aspergillomas can cause hemoptysis due to erosion of the blood vessels in cavity walls, which can often be recurrent, massive, and life‑threatening. Bronchial artery embolization is considered to be the treatment of choice for short‑term control of hemoptysis, and lobectomy as the definitive treatment for aspergilloma. We present a unique observation in two cases of aspergilloma where the fungal balls disappeared radiologically after bronchial artery embolization performed for massive hemoptysis. Key words: Aspergilloma; bronchial artery embolization; hemoptysis Introduction antifungals. We present two cases with long‑standing aspergilloma presenting with massive hemoptysis where Aspergillomas are balls of Aspergillus fumigatus, a saprophytic the fungal balls radiologically disappeared promptly after fungus, which in the lung, colonizes pre‑existing cavities.[1‑3] bronchial artery embolization without recurrence during a Healed tubercular cavities are the most common nidus for follow‑up period of 6 months; such an event is undescribed aspergilloma. These fungal balls can erode blood vessels as yet. in the cavity walls causing hemoptysis, which is the main symptom. Antifungal agents have poor penetration into Case Reports the cavity and are ineffective against fungal balls. Surgery in the form of lobectomy is considered to be the definitive Case report 1 treatment of aspergilloma. Bronchial artery embolization A 53‑year‑old male patient presented to the casualty has been widely utilized and is considered the treatment of department with massive hemoptysis (approximately choice for short‑term control of hemoptysis.[4‑8] Aspergilloma 1 liter over a period of 36 hours). He had tachycardia are known to disappear spontaneously by being coughed (132 bpm) and his blood pressure was 90/50 mmHg. He out as black material or after topical administration of had history of tuberculosis and had undergone complete Access this article online This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows Quick Response Code: others to remix, tweak, and build upon the work non‑commercially, as long as the Website: author is credited and the new creations are licensed under the identical terms. www.ijri.org For reprints contact: [email protected] DOI: 10.4103/ijri.IJRI_335_16 Cite this article as: Prasad B, Ray B. Singular observation of a desirable change after bronchial artery embolization for hemoptysis in intracavitary aspergilloma. Indian J Radiol Imaging 2017;27:225‑8. © 2017 Indian Journal of Radiology and Imaging | Published by Wolters Kluwer - Medknow 225 Prasad and Ray: BAE for aspergilloma treatment 28 years back, which left him with a cavity in the failed to control hemoptysis and the patient had received right upper lobe. He had been having multiple episodes of two units of packed cells. On examination, he was pale, hemoptysis in the last 5 years, and was radiographically had mild tachycardia (120 bpm), and his blood pressure diagnosed to have aspergilloma 4.5 years back. He had been was 110/60 mmHg. He had history of tuberculosis 10 years admitted six times in the last 5 years for life‑threatening back and had undergone complete treatment. He had been hemoptysis, and was managed conservatively with having recurrent episodes of haemoptysis over the last three anti‑thrombolytic medication and blood transfusion. years and previous radiographs taken over the period had Serial radiographs taken over the period had documented documented a small cavity in the left upper lobe with a persisting aspergilloma in the cavity. persisting fungal ball. A radiograph showed a cavity in the right upper lobe with A radiograph showed a cavity with fungal ball in the left a fungal ball [Figure 1A]. Contrast‑enhanced computed upper lobe [Figure 4A]. Contrast enhanced CT performed tomography (CT) was performed in view of mapping to map bronchial vessels showed a cavity with a fungal bronchial vessels contemplating embolization, which ball in the left upper lobe [Figure 4B], and a single confirmed the presence of fungal ball [Figure 1B and C], enlarged left bronchial vessel. A sputum sample of this and showed two large right bronchial vessels leading to the patient was sent for culture, which later grew Aspergillus right upper lobe. Both these vessels were angiographically fumigatus. The enlarged vessel [Figure 5A] was uneventfully assessed [Figure 2] and uneventfully embolized to embolized to stasis using 355–500‑µ sized polyvinyl alcohol stasis using 355–500‑µ sized polyvinyl alcohol particles particles (Contour® PVA Embolization Particles, Boston (Contour® PVA Embolization Particles, Boston Scientific, Scientific, Natick, MA) injected through a securely placed 4F Natick, MA) injected through a securely placed 4F Cobra Judkin’s left coronary catheter (Cordis Corp., Johnson and catheter (Cook Medical Inc., Bloomington, USA) within Johnson, New Jersey, USA) within the artery. Hemoptysis these vessels, following which hemoptysis ceased within 4 stopped completely within 6 hours after embolization. hours. A radiograph performed before discharge and the Radiograph taken before discharge showed the persisting day after embolization showed persistent fungal ball in the fungal ball, which had disappeared as seen in a radiograph cavity and the patient was asked to revisit after 2 weeks. and limited non‑contrast CT sections taken on follow‑up after 2 weeks [Figure 5B]. The patient was completely The patient became completely asymptomatic and a asymptomatic with no recurrence of symptoms or fungal radiograph taken during the follow‑up visit showed ball over a follow‑up period of 6 months. disappearance of aspergilloma [Figure 3]. There had been no recurrence of symptoms over a follow‑up period of Discussion 6 months. Fungi of the Aspergillus species and their spores are found Case report 2 in the environment ubiquitously throughout the world.[1‑3] A 32‑year‑old male patient was referred from an adjacent Healthy population do not develop infection because of hospital presenting with severe hemoptysis amounting the presence of normal mucociliary clearance and alveolar to approximately 500 ml per day for the last 3 days. macrophages. In the presence of a locally immunodeficient Conservative management with an anti‑thrombolytic had pre‑existing lung cavity due to tuberculosis, bronchiectasis, sarcoidosis, interstitial pneumonia, etc., Aspergillus can colonize and form a ball of mycelium, debris, and B A C A B Figure 1 (A-C): Radiograph (A) of the chest showing fibrosis in the right Figure 2 (A and B): (A and B) Cine angiography pictures showing upper lobe with a cavity harboring a fungal ball (*). Supine (B) and prone two tortuous and hypertrophied right bronchial vessels arising from (C) computed tomography images through the cavity confirming the the proximal descending aorta supplying an abnormal hypervascular diagnosis of the fungal ball by demonstrating its mobility within the cavity bed in the right upper lobe 226 Indian Journal of Radiology and Imaging / Volume 27 / Issue 2 / April - June 2017 Prasad and Ray: BAE for aspergilloma A B Figure 4 (A and B): (A) Radiograph of chest showing a cavity (arrows) in the left upper lobe demonstrating a fungal ball (*) and an air‑meniscus. Computed tomography image (B) through the cavity confirming the presence of a fungal ball (*) include topical antifungal instillation percutaneously or transbronchially and have shown variable results.[2] These methods are not free of complications as antifungals can cause chemical‑induced bronchitis and flare up a background pulmonary fibrosis; there can also be procedure‑related complications such as pneumothorax.[2] Figure 3: Radiograph of the chest taken 2 weeks after embolization showing clear cavity devoid of aspergilloma (*) Massive (defined as blood loss of >300 ml in a day or >100 ml per day for 3 consecutive days), recurrent, altered blood elements called aspergilloma.[2] This derives or persistent hemoptysis is the major indication for the nutrition from the walls of the cavity which are fed by treatment of aspergilloma. Less popular forms of hemoptysis inflammation‑induced angiogenesis from the bronchial control, including intracavitary antifungal instillation and circulation. Erosion of such collateral vessels can result hemostatic radiotherapy, are yet to be standardized and in hemoptysis, which is the most common presentation completely evaluated.[12,13] Bronchial artery embolization has of aspergilloma. Rarely, fungal mycelium can invade been evaluated for control of hemoptysis in aspergilloma the adjacent lung tissue causing necotizing pulmonary in various studies and is considered to be the first line aspergillosis.[2] therapy, and as a method of hemodynamic stabilization before more definitive
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