eMedicine Specialties > Radiology > Chest

Aspergillosis, Thoracic: Follow-up

Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP, Chairman of Medical Imaging, Professor of Radiology, NGHA, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Coauthor(s): Sarah Al Ghanem, MBBS, Consulting Staff, Department of Medical Imaging, King Fahad National Guard Hospital, Riyadh, Saudi Arabia; Klaus L Irion, MD, PhD, Consulting Staff, The Cardiothoracic Centre Liverpool NHS Trust, The Royal Liverpool University Hospital, UK; Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute; Carolyn M Allen, MB, BCh, MRCP, FRCR, CCST, Consultant Radiologist, Department of Clinical Radiology, North Manchester General Hospital, UK
Contributor Information and Disclosures

Updated: May 1, 2008

Intervention

Massive hemoptysis may complicate a mycetoma. Surgical resection of the cavity is the treatment of choice. Contraindications to surgery include bilateral advanced lung disease, large transpleural blood vessels, failure to identify the bleeding site, and continued hemoptysis after previous surgery. Bronchial artery embolization is a valuable technique in patients with persistent hemoptysis who are not surgical candidates.

Before bronchial artery embolization is attempted, angiography is performed to assess the bronchial arterial anatomy, nonbronchial systemic blood supply to the mycetoma, and presence and extent of any contribution of blood supply from the pulmonary artery (see Images 11 and 12). The technique involves selective bronchial artery catheterization with a femorovisceral 5-French end-hole catheter. After a preliminary bronchial angiogram study is performed, the catheter is securely inserted into the bronchial artery to be embolized. A coaxial catheter may be required for more selective and more distal placement.

Various embolic agents can be used; the simplest material is polyvinyl alcohol (PVA), a particulate agent that is available in a variety of sizes. Because mycetomas can derive their blood supply from the intercostal arteries, the thyrocervical trunks and pulmonary arteries may also need to be selectively embolized (see Images 13-18).

Percutaneous CT- or fluoroscopically guided intracavitary injection of a paste containing glycerin and amphotericin B or other fungal agents has been successful in the treatment of aspergillomas and chronic necrotizing aspergillosis. The fungal ball partially or completely resolved in 75% of patients. The intracavitary instillation of sodium or potassium iodide has also been used successfully in the treatment of hemoptysis in patients who are not surgical candidates.13

Medicolegal Pitfalls

  • Chest pain may occur, particularly after embolization of an intercostal artery.
  • Rarely, mild dysphagia may occur as a result of an interruption of blood supply to the mid esophagus. This dysphagia is self-limiting and resolves spontaneously.
  • Transverse myelitis and bronchial necrosis are the most serious complications; fortunately, these are rare.

Related Medscape topic:
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Special Concerns

  • Most case reports of transverse myelitis are historical and were most probably related to contrast agent toxicity.
  • Bronchial necrosis is more frequently encountered when absolute alcohol is used for embolization.
  • Nontarget embolization leading to infarction is also reported. This complication is less likely to occur when a superselective approach with an end-hole catheter is used.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Dr Hari Panigrahi to the development and writing of this article.



More on Aspergillosis, Thoracic

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Imaging: Aspergillosis, Thoracic
Follow-up: Aspergillosis, Thoracic
Multimedia: Aspergillosis, Thoracic
References
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References

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Further Reading

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Keywords

pulmonary aspergillosis, Aspergillus fumigatus, A fumigatus, allergic bronchopulmonary aspergillosis, ABPA, saprophytic aspergillosis, aspergilloma, chronic necrotizing aspergillosis, airway-invasive aspergillosis, semi-invasive aspergillosis, angioinvasive aspergillosis, finger-in-glove sign, tree-in-bud sign, air-crescent sign

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Contributor Information and Disclosures

Author

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP, Chairman of Medical Imaging, Professor of Radiology, NGHA, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP is a member of the following medical societies: American Institute of Ultrasound in Medicine, Radiological Society of North America, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Sarah Al Ghanem, MBBS, Consulting Staff, Department of Medical Imaging, King Fahad National Guard Hospital, Riyadh, Saudi Arabia
Disclosure: Nothing to disclose.

Klaus L Irion, MD, PhD, Consulting Staff, The Cardiothoracic Centre Liverpool NHS Trust, The Royal Liverpool University Hospital, UK
Klaus L Irion, MD, PhD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Sumaira MacDonald, MBChB, PhD, MRCP, FRCR is a member of the following medical societies: British Medical Association, Royal College of Physicians, and Royal College of Radiologists
Disclosure: Nothing to disclose.

Carolyn M Allen, MB, BCh, MRCP, FRCR, CCST, Consultant Radiologist, Department of Clinical Radiology, North Manchester General Hospital, UK
Carolyn M Allen, MB, BCh, MRCP, FRCR, CCST is a member of the following medical societies: Society of Thoracic Radiology
Disclosure: Nothing to disclose.

Medical Editor

Satinder P Singh, MD, Associate Professor of Radiology, Chief of Cardiopulmonary Radiology, Director of Cardiac CT, Director of Combined Cardiopulmonary and Abdominal Radiology, Department of Radiology, University of Alabama at Birmingham
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Eric J Stern, MD, Professor of Radiology, Adjunct Professor of Medicine, Adjunct Professor of Medical Education and Biomedical Informatics, University of Washington School of Medicine; Director of Thoracic Imaging, Harborview Medical Center; Associate Medical Staff, Seattle Cancer Care Alliance
Eric J Stern, MD is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, European Society of Radiology, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Barry H Gross, MD, Professor, Department of Radiology, University of Michigan Medical School; Professor, University of Michigan Cancer Center
Barry H Gross, MD is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Michigan State Medical Society, Physicians for Social Responsibility, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

 
 
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