Spore Wars: A Comprehensive Review of Pulmonary Aspergilloma and Its Clinical Management.

Abstract

Pulmonary aspergilloma are characterized by a fungal ball that forms in a pre-existing lung cavity. While many patients remain asymptomatic, others may develop progressive symptoms including cough, hemoptysis, weight loss, fever, and, in severe cases, death. Management is often complex and highly patient-centered, ranging from routine surveillance in stable patients to invasive procedural or surgical approaches in those with more severe disease. Systemic antifungal therapy is generally not indicated for stable, asymptomatic simple aspergilloma, but may be considered in select scenarios such as symptomatic or progressive disease in non-surgical candidates, peri-procedural/perioperative settings or when overlapping CPA phenotypes (e.g., CCPA) are suspected. However, despite the significant morbidity and mortality associated with pulmonary mycetoma, there is a paucity in our understanding of their natural course, optimal treatment modalities and duration, appropriate follow-up plan and prognostication. Consequently, clinical decision-making is frequently based on clinician experience or institutional protocols. In this article, we provide a comprehensive review of pulmonary aspergilloma and its management, with the goal of presenting a practical and evidence-based framework to support clinicians in the evaluation and treatment of this chronic fungal disease.