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CHEST RADIOLOGY Table of Contents   
Year : 1999  |  Volume : 9  |  Issue : 3  |  Page : 107-112
Allergic bronchopulmonary aspergillasis : The spectrum of roentgenologic appearances

Department of Clinical Research, Vallabhbhai Patel Chest Institute, University of Delhi-110007, India

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Keywords: Allergic bronchopulmonary aspergillosis, abpa, Fungal infection

How to cite this article:
Shah A, Panchal N, Agarwal AK. Allergic bronchopulmonary aspergillasis : The spectrum of roentgenologic appearances. Indian J Radiol Imaging 1999;9:107-12

How to cite this URL:
Shah A, Panchal N, Agarwal AK. Allergic bronchopulmonary aspergillasis : The spectrum of roentgenologic appearances. Indian J Radiol Imaging [serial online] 1999 [cited 2020 Jul 6];9:107-12. Available from:
Allergic bronchopulmonary aspergillosis (ABPA), a potentially destructive lung disease now recognized globally, is not uncommon in India [1]. Radiological techniques have been crucial to the diagnosis of the disease. Not only do imaging techniques help establish the diagnosis, but the also help monitor the progress of the disease. Although the disease has received international attention, it is still not diagnosed as frequently and as early as it should be. This results in patients receiving inappropriate therapy leading to lung damage which could have been prevented with early diagnosis.

   Diagnostic Criteria Top

A series of diagnostic criteria [2] has been evolved. These include asthma, history of radiological infiltrates, immediate cutaneous reactivity to A. fumigatus, elevated total serum IgE, precipitating antibodies to A. fumigatus, peripheral blood eosinophilia, elevated serum IgG and IgE to A. fumigatus and central/proximal bronchiectasis with normal tapering of distal bronchi. Other minor criteria are expectoration of golden brownish sputum plugs, positive sputum culture for Aspergillus species and late (Arthus type) skin reactivity to A. fumigatus. A series of diagnostic criteria is necessary because apart from demonstration of central bronchiectasis there is no other test, which establishes the diagnosis or is not affected by therapy with oral prednisolone. Symptoms appear to bear little or no relationship to the severity or chronicity of the disease as one third of the patients may be relatively asymptomatic despite extensive radiographic lesions [3]. It is believed that bronchiectasis occurs in areas previously affected by eosinophilic pneumonitis and progresses to parenchymal fibrosis [4].

   Roentgenologic Manifestations Top

Plain Roentgenologic Appearances

Allergic bronchopulmonary aspergillosis causes a wide spectrum of plain chest radiographic appearances. The changes can be either transient (temporary) or permanent (fixed).

   Transient Changes Top

These opacities [5] appear and disappear at the same and in different sites in the lung over a period of time and affect a segment, a lobe or the whole lung. Although these changes reflect disease activity, they are not pathognomonic of ABPA. No area of the lung remains unaffected, but the upper lobes are predominantly involved. The most commonly observed pattern is consolidation [Figure - 1] or non-homogeneous infiltration [Figure - 2] produced as a result of parenchymal infiltration by inflammatory cells especially eosinophils. Chest radiological changes can closely resemble those seen in tuberculosis, but serial radiographs in ABPA may reveal the transient nature of these pulmonary infiltrates, also known as 'fleeting opacities' [Figure - 1]. Perihilar infiltrates may simulate hilar adenopathy in ABPA [Figure - 1]a,b [5]. Mucoid impaction and retention of respiratory secretions [Figure - 2],[Figure - 3],[Figure - 4],[Figure - 5]a in the distorted bronchi cause a variety of patterns such as 'toothpaste' shadows [Figure - 1]b and 'gloved fingers' shadows. Air-fluid levels [Figure - 2],[Figure - 3] are seen when dilated central bronchi are filled with fluid secretions and debris. The patient may also present with lobar or segmental collapse. ABPA is also reported to present as a case of middle lobe syndrome [6]. Another sign commonly observed known as the 'tramline' sign represents bronchial wall edema. Ipsilateral pleural effusion with collapse has also been reported [7].

[Figure - 1]a,b,c Transient pulmonary infiltrates in a 27-year old man with ABPA. Postero-anterior chest radiograph (A), shows a non-homogeneous consolidation (short arrow) in right mid-zone. Left perihilar infiltrates simulating hilar adenopathy (arrowhead) along with parallel-line opacities in the left mid-zone (long arrow) are also visible. Postero-anterior chest radiograph of the same patient (B) taken after seven weeks shows significant clearing of the nonhomogeneous consolidation in the right mid-zone. Left perihilar infiltrates are still present (arrowhead) while a new 'toothpaste-shadow' (arrow) has appeared exactly at the site of the parallel-line opacities seen in (A). Postero-anterior chest radiograph (C) taken after a further twelve weeks shows reappearance of the consolidation in the right upper and mid-zones (arrow) with partial clearing of the left perihilar infiltrates. The 'toothpaste shadow' seen in (B) has disappeared.

All these opacities are frequently seen in either the acute or the exacerbation stage of the disease and subside either spontaneously or on treatment with corticosteroids.

   Permanent Changes Top

These opacities [5] reflect the permanent, irreversible, fibrotic changes that have occurred in the bronchial walls and parenchyma and tend to persist throughout life even when the patient goes into a remission. Of the permanent changes, the most important one is central bronchiectasis with normal peripheral bronchi, a feature pathognomonic of ABPA. On plain chest radiographs, bronchiectasis is seen as parallel-line opacities [Figure - 1],[Figure - 4] representing bronchial widening or as ring opacities [Figure - 1]a,[Figure - 5]a 1-2 cm in diameter representing dilated bronchi en face. Parenchymal fibrosis [Figure - 6]a may present as linear scars, reticulolinear markings or sometimes with a honeycomb appearance. Other permanent changes such as cavitation [Figure - 6]a, [Figure - 7], contracted upper lobes [Figure - 6]a and localised emphysema are seen. Although cavitation is not a common feature of ABPA, it can occur along with the fibrotic stage of ABPA wherein it may be difficult to distinguish the disease from fibrocavitary pulmonary tuberculosis [8].

   Demonstration of Central Bronchiectasis Top

Demonstration of central bronchiectasis is considered a sine qua non for the diagnosis of the disease and when present can be categorized as ABPA-CB [2]. It is now recognized that patients presenting at an earlier stage of the disease or with a milder form of the disease may not have central bronchiectasis. Such seropositive patients who satisfy all the criteria for ABPA except central bronchiectasis may be categorized as ABPA-S and treatment commenced to prevent further lung damage [2]. Bronchography, which was regarded as a gold standard for the demonstration of central bronchiectasis, gives a one time complete picture of the whole tracheobronchial tree. The classical lesion is a localised area of varicose bronchiectasis affecting the medium-sized bronchi proximally, with normal tapering bronchi distally [Figure 8a]. However, central bronchiectasis may extend to the periphery in a small number of segments [Figure 6b], [Figure - 9] [9]. Marked variations occur in the extent, type and site of bronchiectasis [Figure - 6]b, [Figure - 8]a,[Figure - 9] in the same or different patients. Bronchiectasis on CT commonly shows a 'string of pearl' [Figure - 5]b, [Figure - 8]B or 'signet ring' appearance [Figure - 5]b, [Figure - 11]. Recently we have shown that CT, in comparison to bronchography, a procedure thought to be unsafe in asthma, has a sensitivity of 83% and a specificity of 92% in detecting central bronchiectasis in patients with ABPA and could thus be the investigation of choice [10]. CT scans also enable us to rapidly and safely establish the diagnosis in children with ABPA who present with acute severe asthma [11]. CT of the thorax is now accepted as an effective alternative for the diagnosis of bronchiectasis.

Computed Tomography Appearances

The role of CT in the demonstration of central bronchiectasis, which is still considered a sine qua non for the diagnosis of ABPA, has already been discussed. Other bronchial abnormalities observed on CT in our study [9] were: - dilated and totally occluded bronchi (48%) as evidenced by beaded, tubular opacities and dense, circular opacities [Figure - 10], air-fluid levels within dilated bronchi (22%), bronchial wall thickening (10%) and parallel-line opacities extending to the periphery (30%). On high-resolution CT, high-attenuation mucus plugs have also been reported in 28% of patients with ABPA [12]. Atelectasis, due to proximal mucoid impaction can sometimes be a presenting feature. The atelectasis may be segmental, lobar or may involve the entire lung [13]. Parenchymal abnormalities observed by us [9] were in the form of consolidation (43%) [Figure - 11], non-homogeneous patchy consolidation (67%), collapse (17%), parenchymal scarring of varying extent (83%), cavities (13%) and emphysematous bullae (4%). Involvement of pleura with thickening has also been observed. In our series, the pleura was involved in 43% of patients [9]. This is yet to receive recognition and may not be of major clinical significance. Our recent study has shown that CT of the thorax can provide a sensitive method for the assessment of bronchial, parenchymal and pleural abnormalities in patients with ABPA and should constitute a part of the diagnostic work-up of the disease along with plain chest radiographs.

In conclusion, a high index of suspicion is required to establish a diagnosis of ABPA. The remarkable radiological similarity to pulmonary tuberculosis has important clinical implications as patients with ABPA, especially in our country, often receive antituberculous therapy for a long time while lung damage continues to progress silently. Early diagnosis and appropriate therapy could alter the progress of the disease and prevent the development of end-stage lung fibrosis.

   References Top

1.Shah A. Editorial - Allergic bronchopulmonary aspergillosis: An emerging disease in India. Indian J Chest Dis Allied Sci 1994; 36: 169-172.   Back to cited text no. 1  [PUBMED]  
2.Greenberger PA. Allergic bronchopulmonary aspergillosis. In: Middleton E Jr, Reed CE, Ellis EF, Franklin AN Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice. 4th ed. St. Louis: CV Mosby Co, 1993; 1395-1414.   Back to cited text no. 2    
3.Shah A. Allergic bronchopulmonary aspergillosis. Indian J Chest Dis Allied Sci 1998; 40: 41-54.   Back to cited text no. 3  [PUBMED]  
4.Safirstein BH, D'Souza MF, Simon G, Tai EHC, Pepys J. Five year follow up of bronchopulmonary aspergillosis. Am Rev Respir Dis 1973; 108:450-459.   Back to cited text no. 4    
5.Mintzer RA, Rogers LF, Kruglik GD. The spectrum of radiological findings in allergic bronchopulmonary aspergillosis. Radiology 1978; 127: 301-307.   Back to cited text no. 5    
6.Shah A, Bhagat R, Panchal N, Jaggi OP, Khan ZU. Allergic bronchopulmonary aspergillosis with middle lobe syndrome and allergic Aspergillus sinusitis. Eur Respir J 1993; 6: 917-918.   Back to cited text no. 6  [PUBMED]  
7.Bhagat R, Shah A, Jaggi Op, Khan ZU. Concomitant allergic bronchopulmonary aspergillosis and allergic Aspergillus sinusitis with an operated aspergilloma. J Allergy Clin Immunol 1993; 91: 1094-1096.   Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Shah A, Khan ZU, Chaturvedi S, Ramachandran S, Randhawa HS, Jaggi OP. Allergic bronchopulmonary aspergillosis with co-existent aspergilloma: A long term follow up. J Asthma 1989; 26: 109-115.   Back to cited text no. 8    
9.Panchal N, Bhagat R, Pant C, Shah A. Allergic bronchopulmonary aspergillosis: The spectrum of computed tomography appearances. Respir Med 1997; 91: 213-219.   Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Panchal N, Pant CS, Bhagat R, Shah A. Central bronchiectasis in allergic bronchopulmonary aspergillosis: Comparative evaluation of computed tomography of the thorax with bronchography. Eur Respir J 1994; 7: 1290-1293.   Back to cited text no. 10    
11.Shah A, Pant CS, Bhagat R, Panchal N. CT in childhood allergic bronchopulmonary aspergillosis. Pediatr Radiol 1992; 22: 227-228.   Back to cited text no. 11  [PUBMED]  
12.Logan PM, Muller NL. High-attenuation mucous plugging in allergic bronchopulmonary aspergillosis. Can Assoc Radiol J 1996; 47: 374-377.   Back to cited text no. 12  [PUBMED]  
13.Lynch DA. Imaging of asthma and allergic bronchopulmonary mycosis. Radiol Clin North Am 1998; 36: 129-142.  Back to cited text no. 13  [PUBMED]  

Correspondence Address:
Ashok Shah
Department of Clinical Research, Vallabhbhai Patel Chest Institute, University of Delhi, P.O. Box 2101, Delhi-110007
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11]

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