To Editor:

Aspergilloma is an uncommon infection usually with invasion of lung cavities, often posing diagnostic challenges, and surgical treatment is not consensual.^1),(2 Clinical manifestations of aspergillosis include allergic bronchopulmonary and chronic necrotizing pulmonary disease, aspergilloma, and invasive infections.^1),(2 The diagnosis of pulmonary aspergillosis should be based on classical images, positive serology test, or culture isolation of Aspergillus from respiratory tract.^1),(2

I read the interesting retrospective review by Zotes-Valdivia et al. about results of the surgical management of 12 female and 10 male Mexican patients with pulmonary aspergillosis.¹ The average age was 55 years, 54.5% of them had antecedent of pulmonary tuberculosis, and 77.7% underwent lobectomy.¹ Worthy of note, only one of the 22 patients died - mortality rate lower than 6%;the old patient had postoperative hypovolemic shock and acute renal failure.¹ The authors emphasized three capital issues - the scarce number of studies evaluating the postoperative quality of life, the role of lobectomy as the first option procedure, and the challenges involved in the diagnosis of aspergilloma.¹ Indeed, the establishment of this diagnosis was possible in only 71% of cases.¹

The mentioned study is very well described, but I would like to add comments about a Brazilian case study, which involved an aspergilloma and lung cancer.² Dos Santos et al. described a case of aspergillosis on the site of metastatic lung adenocarcinoma, presenting with images mimicking a pulmonary aspergilloma.² The old Brazilian male had lung adenocarcinoma on the right upper lobe, treated with chemotherapy and corticosteroid, and a metastasis in the left lung.² A thin-walled cavity with a fungus-ball image developed at the site of implant, and bronchoalveolar aspirate and mycological cultures showed Aspergillus spp. Differing from the majority of cases, the sputum was thick and without blood.^1),(2 The patient underwent a schedule of intravenous followed by oral voriconazole, and his pulmonary infection was controlled without need of surgical procedure.² Therefore, the pulmonary cavity showed total regression with clinical treatment. The authors highlighted the possibility of diagnostic pitfalls between lung nodule cavitation by necrotizing aspergillosis, and central necrosis occurring in a metastatic pulmonary nodule, with debris in the cavity mimicking aspergilloma.²

In this setting, both Mexican and Brazilian authors agreed with respect to the need of better evaluation about the role of preoperative antifungal treatments.^1),(2

The herein commented manuscripts may improve the suspicion index of non-specialists about this uncommon fungal infection, in addition to stimulate more researches with large sample size to accurately establish the surgical options.^1),(2