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Clinical, radiological, and
microbiological profile of pulmonary
aspergillosis in treated cases of
pulmonary tuberculosis
Website:
www.ijaai.in Shubhra Jain, Yogendra Singh Rathore, Vinod Joshi, Narendra Khippal
DOI:
10.4103/ijaai.ijaai_18_18
Abstract:
CONTEXT:  Clinical studies about detailed spectrum of aspergillosis in treated tuberculosis (TB)
patients are lacking. Hence, a study was undertaken at the Institute of Respiratory Disease, Jaipur,
Rajasthan, India. Treated patients of pulmonary TB having any symptom such as hemoptysis, cough
with expectoration, weight loss, and whose chest X‑ray showed residual cavitation were enrolled
for the study.
AIMS: This study aimed to determine the prevalence of pulmonary aspergillosis in treated cases of
pulmonary TB and to study the social, demographical, and clinical characteristics of these patients.
SETTINGS AND DESIGN: A descriptive type of observational study was conducted at the Department
of Respiratory Medicine in a tertiary care center of Rajasthan.
SUBJECTS AND METHODS: This descriptive type of observational study was conducted on seventy
patients, whose sputum or bronchial wash showed isolation of Aspergillus. Demographic details,
predisposing factors, and clinical findings were noted.
STATISTICAL ANALYSIS USED: Data collected were entered into Excel spreadsheet and
quantitative data were expressed as number and percentage.
RESULTS: The presentation of pulmonary aspergillosis in treated cases of pulmonary TB varies from
aspergilloma (57%) to chronic necrotizing pulmonary aspergillosis (36%) to allergic bronchopulmonary
aspergillosis (7%). The most common symptom was recurrent hemoptysis. Most of the patients were
farmers by occupation, but no significant comorbid illness was seen. X‑ray chest missed about 70% of
cases. The most common species were Aspergillus fumigatus; others were Aspergillus terreus (13%),
Aspergillus flavus (13%), and Aspergillus niger (7%).
 CONCLUSIONS: All treated cases of pulmonary TB presenting with recurrent hemoptysis and/or
cough with expectoration should be evaluated in detail for pulmonary aspergillosis as chest X‑ray
alone can miss the diagnosis.
Keywords:
Aspergillosis, hemoptysis, pulmonary tuberculosis

Department of Pulmonary
Medicine, Institute of Introduction traditional risk factors such as neutropenia
Respiratory Disease, SMS are lacking. Aspergillus causes a variety of
Medical College, Jaipur,
Rajasthan, India A spergillus is a ubiquitous saprophytic
mold which includes 200 species.[1,2]
A concerning trend in the epidemiology
pulmonary diseases, mainly aspergilloma,
chronic necrotizing pulmonary aspergillosis
(CNPA), and allergic bronchopulmonary
Address for
correspondence: of pulmonary fungal infection is the aspergillosis (ABPA) in the underlying
Dr. Yogendra Singh increasing incidence of patients in which chronic lung diseases.[3,4] Further, clinical
Rathore, studies about the detailed spectrum of
Room No. 509, This is an open access journal, and articles are distributed aspergillosis in treated tuberculosis (TB)
New Zanana under the terms of the Creative Commons Attribution-
Residency, Jhotwara NonCommercial‑ShareAlike 4.0 License, which allows others to How to cite this article: Jain S, Rathore YS, Joshi V,
Road, Chandpole, remix, tweak, and build upon the work non‑commercially, as long Khippal N. Clinical, radiological, and microbiological
Jaipur ‑ 302 001, as appropriate credit is given and the new creations are licensed profile of pulmonary aspergillosis in treated cases
Rajasthan, India. under the identical terms. of pulmonary tuberculosis. Indian J Allergy Asthma
E‑mail: yrjsr108@ Immunol 2018;32:74-7.
gmail.com For reprints contact: reprints@medknow.com

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Jain, et al.: Pulmonary aspergillosis in treated cases of pulmonary tuberculosis

patients are lacking in India. A study was, therefore, Table 1: Sociodemographic features of cases
undertaken at the Institute of Respiratory Diseases, SMS Sociodemographic characteristics n (%)
Medical College, Jaipur, Rajasthan, India. Gender
Male 28 (40)
Subjects and Methods Female 42 (60)
Age
Old treated patients of pulmonary TB showing <40 42 (60)
cavitary pulmonary lesion with paracavitary infiltrates 40‑60 19 (27.14)
>60 9 (12.85)
or new cavity formation or expansion of cavity size
Occupation
over time or ball‑like lesions inside the old cavities or
Farmer 33 (47.14)
a recent thickening of cavity wall were enrolled and
Laborer 12 (17.14)
subjected to further clinical assessment and laboratory
Others 25 (35.72)
investigations including complete blood count, blood
sugar, urea, human immunodeficiency virus  (HIV)
serology, urine examination, sputum for Ziehl–Neelsen Table 2: Reported symptomatology of cases
stain, BACTEC culture for Mycobacterium tuberculosis, Symptoms n (%)
fungal potassium hydroxide mount, and culture. Hemoptysis* 51 (72.93)
Patients with evidence of active pulmonary TB, Wet cough* 25 (35.75)
HIV, or clinicoradiological evidence of improvement Chest pain* 23 (32.89)
on antibiotics were excluded from the study. Weight loss* 18 (25.74)
Bronchoscopy was performed in two patients. Dyspnea* 14 (20.02)
Fever* 14 (20.02)
Seventy patients whose sputum and/or bronchial
Dry cough* 2 (2.86)
wash showed isolation of Aspergillus were included
None 11 (15.73)
in the study. Daniel criteria were used to diagnose
*Symptoms reported were overlapping each other in some patients
aspergilloma and CNPA in residual cavitary lesions
and Rosenberg–Patterson criteria were used to
diagnose ABPA.[5,6] Table 3: Relevant clinical history of cases
Clinical characteristics n (%)
Duration of illness (years)
Results <1 19 (27.17)
1‑2 37 (52.91)
The intake of patients for the study started in July 2016
>2 14 (20.02)
and was completed in December 2017. After exclusion, a
Past history of ATT (years)
total of 110 treated pulmonary TB patients who presented <10 42 (60.00)
symptomatically with sputum smear negative were 10‑20 19 (27.17)
examined, out of which 70 (63.6%) were found to have >20 9 (12.83)
aspergillosis, thus included in the study. The mean age Addiction
of the study patients was 42.8 ± 17.2 years. Females Ex‑smoker 23 (32.88)
outnumbered males by a ratio of 3:2. By occupation, Smoker 14 (20.02)
33 patients were farmer and 12 were laborer [Table 1]. Alcoholic 5 (7.10)
Hemoptysis (72.93%) of varying severity was the most No addiction 28 (40.00)
common symptom, followed by wet cough (35.75%), chest Comorbidities
pain (32.89%), weight loss (25.74%), dyspnea (20.02%), Anemia 35 (50.00)
fever (20.02%), and dry cough (2.86%) [Table 2]. Asthma 9 (12.83)
Comorbidities such as anemia, asthma, diabetes mellitus, DM 5 (7.10)
and hypertension were present in 50%, 12.83%, 7.10%, HT 5 (7.10)
and 7.10% of patients, respectively, and no comorbidities None 16 (22.88)
DM=Diabetes mellitus, HT=Hypertension, ATT=Anti‑tuberculosis therapy
were found in 22.88% of patients. The duration of
illness was <1 year, 1–2 years, and >2 years in 27.17%,
52.91%, and 20.02% of patients, respectively [Table 3]. was the most common species isolated in 47 patients
Chest X‑ray showed fibrocavitary disease (50%), followed by Aspergillus terreus (9), Aspergillus flavus (9),
aspergilloma (22.88%), bronchiectasis (20.02%), and and Aspergillus niger (5) [Table 5].
patchy infiltrate  (7.15%). Computed tomography  (CT)
scan was suggestive of aspergilloma in 72.88% of Aspergilloma was diagnosed in forty patients (57%) on
patients, fibrocavitary disease in 50% of patients, pleural the basis of Monad’s sign and fungal culture. Thirty‑five
thickening in 25.74% of patients, and bronchiectasis patients (36%) were diagnosed with CNPA on the basis
in 22.88% of patients [Table 4]. Aspergillus fumigatus of clinical, radiological, and microbiological criteria.
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Jain, et al.: Pulmonary aspergillosis in treated cases of pulmonary tuberculosis
Table 4: Lesions/pathology reported with chest imaging
Lesions/pathology
Chest skiagram
Fibrocavitary
Aspergilloma
Bronchiectasis
Patchy infiltrates
CT chest*
Aspergilloma
Fibrocavitary
PL thickening
Bronchiectasis
*Overlapping in CT results. CT=Computed tomography, PL=Pleural
Table 5: Distribution of cases according to species of
Aspergillus detected
Species
Aspergillus fumigatus
Aspergillus terreus
Aspergillus flavus
Aspergillus niger
Table 6: Forms of aspergillosis
Type
Aspergilloma
CNPA
ABPA
CNPA=Chronic necrotizing pulmonary aspergillosis, ABPA=Allergic
bronchopulmonary aspergillosis
Only five patients (7%) had ABPA without peripheral
eosinophilia [Table 6].
Discussion
Aspergillus species are commonly found in every
region of the world. Aspergillus species are commonly
found in soil and decaying vegetation. They can
be found in household dust, building materials,
ornamental plants, flower arrangements, tobacco,
food, and water. Conditions enhancing dispersal of
molds are activities such as construction, demolition,
excavation, disturbance of dust accumulations
during routine cleaning, water leaks, and moisture
accumulation.[7] Among them, twenty are pathogenic
in humans. Aspergillus species release conidia at high
concentrations (1–100 conidia/m 3) that are small
enough (2–3 μm) to reach the pulmonary alveoli
and cause a variety of pulmonary diseases. [8] The
presentation of aspergillosis varies from aspergilloma,
CNPA, to ABPA in treated pulmonary TB patients.
Aspergilloma is characterized by classical radiological
Monad’s sign and positive Aspergillus precipitin test
or sputum culture positive for Aspergillus or both.[9]
The demonstration of a mobile mass within a cavity
on supine and prone scans is virtually diagnostic of
76 Indian Journal of Allergy, Asthma and Immunology - Volume 32, Issue 2, July-December 2018
aspergilloma. CNPA is diagnosed by chronic (>1 month)
n (%) pulmonary or systemic symptoms including at least
one of the following: weight loss, productive cough,
35 (50.00) hemoptysis with no overt immunocompromising
16 (22.88) conditions, and radiologically by cavitary pulmonary
14 (20.02) lesion with paracavitary infiltrates or new cavity
5 (7.15) formation or expansion of cavity size over time.[10‑12] The
microbiological criteria included isolation of Aspergillus
51 (72.88)
species from pulmonary or pleural cavity or positive
35 (50.00)
serum Aspergillus precipitin test. ABPA is diagnosed by
18 (25.74)
16 (22.88)
Rosenberg–Patterson criteria which included a history
of asthma and immediate cutaneous hyperreactivity
to Aspergillus antigens or elevated specific serum
IgE and elevated total IgE (>1000 IU/ml) and raised
A. fumigates‑specific IgG or presence of serum precipitins.
n (%)
47 (67.21) Although chest radiography is the initial examination
9 (12.87) of choice, in our study, it could show only 16 cases
9 (12.87) of aspergilloma. CT scan was found to be much more
5 (7.15) superior as it could pick 51 cases of aspergilloma out
of the 70 patients. Furthermore, CT provided useful
information regarding the extent of pulmonary disease
n (%)
and any associated pleural thickening.
40 (57)
25 (36)
A limitation of our study was that anti‑Aspergillus
5 (7) antibody was not done in all suspected patients. If that
could have been included, probably the number of
aspergillosis patients in treated pulmonary TB would
have been higher.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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