Multifocal pulmonary aspergillomas: case series and review.

Multifocal lung parenchymal cavities containing multiple aspergillomas are not well-recognized features of chronic pulmonary aspergillosis (CPA). We identified five patients with multiple cavities containing fungal balls from our accumulated cohort of ∼300 patients with CPA. Corticosteroid exposure and radiological and serological characteristics were assessed. The patients, aged 19-55 years, developed 3-11 cavities (or nodules in one case) with thin walls, usually within the lung parenchyma, with very limited pleural involvement. Four had asthma (severe in three) and one had cystic fibrosis; three had allergic bronchopulmonary aspergillosis. All patients had received corticosteroids orally or by inhalation. Four patients had elevated Aspergillus IgG antibodies; one had elevated Aspergillus-specific IgE. Three patients developed azole resistance on antifungal therapy, after benefit, one of whom underwent a successful bilateral lung transplant, later complicated by a fatal mycotic cerebral aneurysm. Multiple aspergillomas is a new distinct manifestation of CPA. The lack of inflammatory response and the distribution of the cavities in the lungs are remarkable. Aspergillus nodules could evolve into cavities with aspergillomas. The management and development of azole resistance in these patients is problematic.