CTICasesAllergic Bronchopulmonary Aspergillosis in Atypical Distribution
Imaging findings
A retired veterinarian in his 60s, a nonsmoker who had been gardening in Arizona, developed a cough and a lower-lobe-predominant airway-centered process with branching tree-in-bud nodules, mucus plugging, and mild peribronchial consolidation. Some mucus plugs are denser than blood pool on soft-tissue windows. Bronchoscopy showed eosinophils and grew Aspergillus fumigatus, and serum IgE was elevated, without asthma, cystic fibrosis, or much bronchiectasis.
Key takeaways
High-attenuation (dense) mucus plugging is a strong imaging clue to allergic bronchopulmonary aspergillosis, even when the distribution is atypically lower-lobe predominant with little bronchiectasis, as opposed to the usual central varicose bronchiectasis. ABPA is a hypersensitivity reaction to airway Aspergillus and can occur without meeting the traditional asthma or CF criteria, so recognizing the dense mucus prompts the diagnosis and IgE correlates with activity.
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