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Case 333


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Male patient, 47 years old, homeless, smoker (20 pack-years), admitted to the emergency service presenting massive hemoptysis. Pulmonary tuberculosis treated 8 years ago. Urgent rigid bronchoscopy was performed evidencing blood flow through the ostium of the bronchus of the right upper lobe. After stabilization, CT of the chest was requested and, subsequently, right upper lobectomy with posterolateral thoracotomy was performed.

Considering the clinical history and the provided images, what is the most likely diagnosis?

a) Angioinvasive pulmonary aspergillosis


b) Necrotizing pneumonia


c) Pulmonary hydatid cyst


d) Fungus ball (aspergilloma)


Image analysis

Image 1 - Analysis: Computed tomography (CT) of the chest, axial view, at the supra-aortic trunks level, after intravenous administration of iodinated contrast, arterial phase, lung window. Cavitating lesion in the right upper lobe with thickening of the wall (white arrow) containing accumulation of material of soft tissue density and non contrast-enhanced (yellow arrow). Presence of air interposed between the content and the wall of the cavity - air crescent sign (red arrow).


Image 2 - Analysis: Sagittal view of the surgical specimen: right upper lobe of the lung with cavity (white arrow) containing matted hyphae and debris - fungus ball (yellow arrow).



- Fungus ball is a colonization of a preexisting cavity of the lung, commonly related to tuberculosis;

- The most common colonizing fungi is the Aspergillus fumigatus;

- Most patients are asymptomatic but, within the symptoms, hemoptysis is the most common;

- Mobile intracavitary nodule, air crescent sign and Aspergillus serology determine the diagnosis;

- The treatment is surgical as the anatomic resection is the gold standard.



- S. Silva C, L. Müller N. Tórax - Série Colégio Brasileiro de Radiologia e Diagnóstico por Imagem. 1st ed. Rio de Janeiro: Elsevier Editora Ltda.; 2011;

- Passera E, Rizzi A, Robustellini M, Rossi G, Della Pona C, Massera F et al. Pulmonary Aspergilloma. Thoracic Surgery Clinics. 2012;22(3):345-361;

- Marchiori E, Hochhegger B, Zanetti G. Intracavitary nodule. Jornal Brasileiro de Pneumologia. 2016;42(5):309-309;

- Moodley L, Pillay J, Dheda K. Aspergilloma and the surgeon. Journal of Thoracic Disease. 2014;6(3):202-209;

- Ruiz Júnior R, Oliveira F, Piotto B, Muniz F, Cataneo D, Cataneo A. Tratamento cirúrgico de aspergiloma pulmonar. Jornal Brasileiro de Pneumologia. 2010;36(6):779-783.



Gabriella Yuka Shiomatsu, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: gabi.yuka[at]



Dr. Roberto Gonçalves, thoracic surgeon at Santa Isabel Hospital and professor at Medical Science Faculty of Santa Casa de São Paulo.

E-mail: bobtorax[at]



Gabriel Santos, Elaine Iwayama, Fernando Amorim, William Alves, Professor José Nelson Mendes Vieira, Professor Viviane Santuari Parisotto Marino.


Translated by

Gabriella Yuka Shiomatsu, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: gabi.yuka[at]

Test question

(Medical Residency Process 2012 - Universidade Federal do Estado do Rio de Janeiro)

The radiological sign known as the Monod sign is found in:

a) Lung cancer


b) Tuberculosis


c) Sarcoidosis


d) Cryptococcosis


e) Aspergillus fungus ball



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