CTICasesAllergic Bronchopulmonary Aspergillosis with High-Attenuation Mucus
Imaging findings
A CT scout view shows extensive bilateral opacity initially suggesting progressive massive fibrosis, but there is no volume loss, no hilar retraction, and the lungs look large rather than small; the opacities have an unusually sharp, non-ragged border. CT in this asthmatic patient demonstrates widespread bronchial disease with very large branching upper-lobe mucus plugs filling dilated airways, likened to fingers in gloves. On soft-tissue windows the plugs measure denser than skeletal muscle and blood pool.
Key takeaways
High-attenuation mucus is a classic feature of allergic bronchopulmonary aspergillosis. The density reflects accumulated metals rather than any single element: manganese has been implicated, but iron and calcium contribute as well, and iron is probably the main ingredient. Fungi and many other organisms are avid for iron, so its concentration within a colonized mucus plug is expected, and the host counters by raising transferrin during acute infection to sequester iron away from the organisms. Sharp margins and preserved or increased lung volume help distinguish this from progressive massive fibrosis.
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