Pulmonary aspergilloma/Aspergiloma pulmonar

Aspergilloma is an uncommon infection usually with invasion of lung cavities, often posing diagnostic challenges, and surgical treatment is not consensual.1,2 Clinical manifestations of aspergillosis include allergic bronchopulmonary and chronic necrotizing pulmonary disease, aspergilloma, and invasive infections.1,2 The diagnosis of pulmonary aspergillosis should be based on classical images, positive serology test, or culture isolation of Aspergillus from respiratory tract.1,2 I read the interesting retrospective review by ZotesValdivia et al. about results of the surgical management of 12 female and 10 male Mexican patients with pulmonary aspergillosis.1 The average age was 55 years, 54.5% of them had antecedent of pulmonary tuberculosis, and 77.7% underwent lobectomy.1 Worthy of note, only one of the 22 patients died mortality rate lower than 6%;the old patient had postoperative hypovolemic shock and acute renal failure.1 The authors emphasized three capital issues the scarce number of studies evaluating the postoperative quality of life, the role of lobectomy as the first option procedure, and the challenges involved in the diagnosis of aspergilloma.1 Indeed, the establishment of this diagnosis was possible in only 71% of cases.1 The mentioned study is very well described, but I would like to add comments about a Brazilian case study, which involved an aspergilloma and lung cancer.2 Dos Santos et al. described a case of aspergillosis on the site of metastatic lung adenocarcinoma, presenting with images mimicking a pulmonary aspergilloma.2 The old Brazilian male had lung adenocarcinoma on the right upper lobe, treated with chemotherapy and corticosteroid, and a metastasis in the left lung.2 A thin-walled cavity with a fungus-ball image developed at the site of implant, and bronchoalveolar aspirate and mycological cultures showed Aspergillus spp. Differing from the majority of cases, the sputum was thick and without blood.1,2 The patient underwent a schedule of intravenous followed by oral voriconazole, and his pulmonary infection was controlled without need of surgical procedure.2 Therefore, the pulmonary cavity showed total regression with clinical treatment. The authors highlighted the possibility of diagnostic pitfalls between lung nodule cavitation by necrotizing aspergillosis, and central necrosis occurring in a metastatic pulmonary nodule, with debris in the cavity mimicking aspergilloma.2 In this setting, both Mexican and Brazilian authors agreed with respect to the need of better evaluation about the role of preoperative antifungal treatments.1,2 The herein commented manuscripts may improve the suspicion index of non-specialists about this uncommon fungal infection, in addition to stimulate more researches with large sample size to accurately establish the surgical options.1,2