Aspergilloma of lung
Cause of coughing out blood even after a successful treatment of tuberculosis

Dr KK Pandey *

In our country tubercular infection is rampant. The TB infection is gradually acquiring an epidermic form. Every year 30 lacs new cases of tubercular infection come to light in India. The number of deaths occurring due to tuberculosis every year is around 8 lacs. In majority of the tubercular patients, deaths occur due to an inadequate and irregular treatment.

In some tubercular patients, the story does not end with the successful treatment of tubercular infection. In fact, such patients continue to cough out phlegm as well as blood even after a successful treatment of tuberculosis.

A patient, who had previous tubercular infection and successfully treated, is really at loss and unable to understand why he is still not free from complaints of cough and blood even after eradication of tubercular germs from his lung.

During infection period it is quite natural to have the complaint of passage of phlegm and blood while coughing, but after the successful treatment and cure, other complaints like fever, weight loss usually disappear but the problem of recurring episodes of coughing out blood if persists is really perplexing.

A patient fails to understand the exact reason of this recurrent episode, but even our physicians do not realize the exact mechanism causing this problem even after they have given a full successful course of antitubercular treatment. The ultimate result is that they restart a second course of antitubercular treatment for the next six-months. Majority of our physicians have an erroneous notion that, perhaps inadequate control of tubercular infection is the reason for persistent episode of coughing out blood.

Why does a person cough out blood even after cure of tuberculosis of lung ?

The most important cause of ‘coughing out blood’ even after successful treatment of tubercular infection is the presence of a special type of fungus germ called ‘Aspergillus Fumigatus’ which is thread-like in shape. When this fungus makes its permanent abode inside the lung, a sufferer starts coughing out blood repeatedly. What happens after an effective course of antitubercular treatment, tuberculosis does leave the affected lung permanently but before leaving it creates a hollow space or a cavity inside the lung.

To these hollow spaces ‘Aspergillus’ fungus reaches via wind pipes and stays there permanently, exactly the same way as a bird makes its nest in a pre existing hollowed-out space inside the trunk of a tree. Apart from tuberculosis, other diseases like bronchiectasis and chronic pus too are responsible for creating hollow cavities inside the lung.

Besides these, the cancer of lung, disease of sarcoidosis and histoplasmosis also lead to dead hollow spaces inside the lung. These hollow cavities become the favourite spot for ‘Aspergillus’ fungus to stay and thus after sometime this fungus makes a solid fibre ball of threads.

Apart from this, the blood pipes adjacent to these hollowed-out spaces undergo an anatomical change and become very weak. When a person coughs, these weakened blood pipes burst open due to sudden increase in internal pressure and with the result, the affected person starts coughing out blood.

How this fungus makes the hollow space of lung as his permanent residence ?

Why does a‘Aspergillus’ fungus enter these dead hollow spaces is not without some reason. If a patient after being cured of tuberculosis continues to live in an environment devoid of open fresh air and sunlight, this makes an easy entry for fungus germ into these dead hollow spaces of lung. If a person having hollow cavities in his lung spends most of his time in a office room fitted with an artificial ceiling, the possibility of entry of this fungus into the lung increases.

Sometimes, the polluted air in a hospital environment too helps in entry of Aspergillus into the dead space of lung. That is why it becomes all the more important for a person who had treatment of tuberculosis and lung abscess in the past, to avoid going into a polluted environment and should not spend much time in humid and dark rooms, with no sunlight. Such patients should choose a house wherein no overcrowding of family members is there and its rooms should have cross-ventilation and allow inside sunlight for some period of time during the day.

Weak body defence makes a good host for Aspergillus

Aspergillus fungus also attacks those lungs where capacity to fight an infection has gone down, for example transplant patients and a patient who is on a long treatment medicine of ‘steroids’ and ‘prednisolon’. Due to under-nutrition also, the defence mechanism of the body becomes weak.

This facilitates an easy entry of Aspergillus germ into the lung. When this fungus makes the dead space of lung as its permanent address, it multiplies in thousands and creates a dense network in which blood products and destroyed portion of lung get trapped and ultimately the whole thing appears like a ball, which on chest x-ray resemble a white cricket ball. If one looks at the chest x-ray of such patient, it appears as if a white coloured ball is lying in a dark hollow area.

This white ball is called in medical terms as ‘Fungal ball’ meaning thereby a ball made up of fungal germs.

How to recognize Aspergilloma of lung ?

1. Multiple episodes of coughing out either frank blood or bloody sputum
2. Sometimes vomiting of blood
3. Episodes of recurrent infections in lung
4. Frequent incidences of fever, cough and breathlessness
5. Development of pain on left or right side of the chest during breathing

Where to go if a patient is suffering from Aspergilloma?

If sometime back you had undergone treatment for tuberculosis or abscess of lung and already got rid of infection but recently you have developed problem of cough or sometimes coughing out blood or bloody sputum, chances are you are in all probability suffering from aspergilloma of lung (Fungal ball disease). In such a situation you should immediately consult a thoracic surgeon. For investigation of a case of aspergilloma lung, the chest x-ray and multi slice CT scan are very important tools.

The analysis of sputum and CT guided needle biopsy of fungal ball are important. It is not always essential to have the presence of fungal threads of Aspergillus in the sputum as well as in the substance taken out by needle biopsy of the fungal ball. Besides these, sometimes investigation of bronchoscopy and procedure of bronchial artery embolization too are required. Therefore a patient of ‘aspergilloma’ lung should go to a hospital where facility of all these investigations is available. Before entering a hospital make sure whether the availability of a full-time thoracic surgeon is there or not.

Surgery is the best treatment for Aspergilloma

If you are suffering from aspergilloma of lung and frequently cough out blood, amount of which sometimes becomes significant, please do not sit idle, immediately consult an experienced thoracic surgeon, otherwise your life will be in danger if ever a catastrophic bleeding occurs. The permanent and successful treatment of aspergilloma of lung is surgery, this fact should be understood very clearly.

Unless the part of the lung destroyed by aspergilloma is not taken out of the chest, bleeding will never stop during coughing. This operation is called lobectomy. The small operations like removal of fungal ball or only cleaning of the dead hollow space and filling the dead space with medicines and muscles are not reliably effective.

The disadvantages of these small operations are two: firstly it is not a permanent treatment and secondly it increases the possibility of creating pus and infection inside the chest. These small operations are justified only in special conditions where patient is not medically fit for the major operation of lobectomy, for example a very weak, old and malnourished transplant patient admitted in an intensive care unit. This small operation is called ‘cavernostomy’.

Embolization - An effective technique to save the life

Sometimes in emergency, the other method of treatment like Bronchial artery embolization is used. In this procedure the culprit bleeding artery is blocked through angiography in order to control a catastrophic bleeding. But this treatment does not lead to a permanent cure, although this procedure is very effective in saving the life of a patient who might have been dead due to uncontrolled bleeding.

It has been observed in seven out of ten patients treated successfully with this procedure, an episode of coughing out blood recurs within a few days or months after the procedure. This technique is undoubtedly very effective in saving the life of the patient in emergency situations. Therefore such patients should always go to a hospital where facility of angiography and artery embolization is available. For these procedure the availability of a D.S.A laboratory (digital subtraction angiography) is very essential in the hospital.

What to do when surgery is not possible ?

In some patients surgery is not possible. In such cases special medicines, like Variconazole and amphotenicin are given intravenously. There medicines are effective only when whole lung is infected with aspergillus and there is no dead space or aspergilloma. Such condition is called in medical term as ‘Invasive aspergillosis’.

Only in this condition intravenous administration of drug is effective to some extent. But never forget surgery is the only solution and answer for aspergilloma or ‘fungal ball’ of the lung.