Presentation
Long history of asthma and COPD. Recent deterioration in breathlessness.
Patient Data
There is bronchiectasis which is predominantly central in distribution and worse within the mid and lower zones. The predominant pattern is of varicoid bronchiectasis, with regions of more cystic bronchiectasis within the anterior basal segment of the right lower lobe. There are foci of mucous plugging, as well as peri-bronchovascular nodular opacities. Within the right apex there is a larger 12 mm spiculated lesion.
No definite tree in bud opacities are seen. There is minor gas trapping within the right upper zone with emphysematous changes evident.
No hilar or mediastinal lymphadenopathy. No pleural or pericardial effusion.
The imaged upper abdomen is unremarkable.
No suspicious osseous lesion identified.
Conclusion: Central and predominantly mid to lower zone bronchiectasis with mucus plugging and bronchovascular nodularity consistent with allergic bronchopulmonary aspergillosis. The more spiculated 12 mm right upper lobe opacity and apical segment left lower lobe lesions are likely related to previous infection, however, it should be followed up with a repeat CT in 3-6 months to ensure stability given the background emphysematous changes.
Case Discussion
Allergic bronchopulmonary aspergillosis (ABPA) is at one end of the spectrum of disease caused by pulmonary aspergillosis and can be classified as an eosinophilic lung disease.
It is seen is almost only encountered in patients with longstanding asthma, and only occasionally in patients with cystic fibrosis. Only rarely does it appear in patients with no other identifiable pulmonary illness.
CT findings include:
- centrilobular nodules representing dilated and opacified bronchioles
- bronchiectasis
- central, upper lobe saccular bronchiectasis involving segmental and subsegmental bronchi is characteristic
- mucoid impaction results in a bronchocoele, the finger in glove sign
- this may give a Y, V or toothpaste-like like configuration
- centrilobular nodular opacities.
- high attenuation (calcification) in impacted mucus in ~30%
- bronchial wall thickening: common
- chronic disease may progress to pulmonary fibrosis, predominantly in upper lobe
- cavitation: 10%
Treatment of ABPA is difficult due to the ubiquity of Aspergillus in the environment.
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