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Findings:The PA and lateral chest radiograph show large, lobulated perihilar masses. Further evaluation of the left perihilar mass shows a cresentic lucency above the larger soft tissue component. The right perihilar tubular opacities appear to extend to the hilum.
The chest CT shows these large lobulated masses to be contained within larger, cystic cavities which extend to the central hilum.
Diagnosis:Allergic bronchopulmonary aspergillosis (ABPA) with severe central bronchiectasis and central mycetoma formation.
Discussion: Allergic bronchopulmonary aspergillosis (ABPA) accounts for the majority of eosinophilic lung disease. The basis of ABPA is a hypersensitivity to the Aspergillus species that grows in the dilated proximal airways. Aspergillus fumigatus is the species present in nearly 90%. But other common species include A. flavus and A niger. ABPA commonly occurs in a patient with a long history of asthma. There are a number of criteria for ABPA. The major criteria include 1) asthma, 2) blood eosinophilia, 3) immediate skin reactivity to Aspergillus antigen, 4) precipitin antibodies to Aspergillus antigen, 5) raised serum IgE, 6) pulmonary opacities and 7) central bronchiectasis.
Radiographic findings include perihilar consolidations, which often recur in the same locations. Mucoid impaction in areas distal to the diseased central airways is the most characteristic finding in ABPA. The opacities of mucoid impaction correspond to the "toothpaste tube" sign commonly associated with ABPA.
CT scanning has replaced bronchography for the diagnosis of ABPA. Upper lobe central bronchiectasis is a characteristic finding on CT. Atelectasis, scarring and volume loss can occur in those areas most severely affected. Mycetomas will occur in a minority of patients.
References:
Armstrong P, Wilson, AG, Dee P, and Hansell, DM. Imaging of Diseases of the Chest,
2nd Ed., Mosby, 1995, 529-534.
Greenberger PA: Allergic Bronchopulmonary Aspergillosis and Fungoses.
Clin Chest Med 9:599-608, 1988.
Gefter WB, Epstein DM, Miller WT: Allergic Bronchopulmonary Aspergillosis:
Less Common Patterns. Radiology. 140:307-312, 1981.
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