Pulmonary masses in allergic bronchopulmonary aspergillosis: mechanistic explanations.

Allergic bronchopulmonary aspergillosis (ABPA) is a disorder caused by hypersensitivity to Aspergillus antigens, and is currently the best recognized manifestation of Aspergillus-associated hypersensitivity disorders. ABPA occurs in 1–2% of patients with bronchial asthma and 2–15% of patients with cystic fibrosis.1 Patients with ABPA may present with recurrent asthma exacerbations, expectoration of dark brown mucus plugs, hemoptysis, or systemic symptoms such as fever, anorexia, malaise, or weight loss. The Rosenberg criteria2 are most widely used for diagnosis and include 8 major and 3 minor criteria. The major criteria (easily remembered by the mnemonic ARTEPICS) are: A Asthma R Radiographic fleeting pulmonary opacities T Skin test positive (type 1 reaction) for Aspergillus fumigatus E Eosinophilia P Precipitating antibodies (Immunoglobulin G [IgG]) in serum I Immunoglobulin E (IgE) in serum elevated ( 1,000 IU/mL) C Central bronchiectasis S Serum-specific IgG and IgE against A. fumigatus If 6 of the 8 primary criteria are met, the diagnosis is certain. The minor criteria are Aspergillus in sputum, expectoration of brownish-black mucus plugs, and delayed skin reaction to Aspergillus antigen (type 3 reaction). Patients with ABPA present with diverse radiographic manifestations, including finger-in-glove and toothpaste opacities, air-fluid levels from dilated bronchi, and tramline shadows from edematous bronchial walls.3 Highresolution CT characteristically shows central bronchiectasis, mucus-filled bronchi (bronchoceles), consolidation, and tree-in-bud appearance of centri-lobular nodules.4 Pulmonary masses in ABPA are uncommon but have been described in the literature.5-8 Proximal bronchoceles (often inseparable from the hilum) may simulate hilar mass.9 We report 3 patients with pulmonary masses and ABPA. We also discuss mechanisms by which ABPA might lead to such parenchymal lesions.