Aspergilloma and massive haemoptysis

A 40-year-old homeless woman who was a known intravenous drug user and heroin smoker, presented with massive haemoptysis. Initial CT-pulmonary angiogram (CT-PA) did not show active haemorrhage but found an opacity in a right upper lobe cavity likely to represent a mycetoma. She was started on antifungal therapy but haemoptysis persisted and bronchial angiography was performed. Again no active haemorrhage was identified but abnormal vasculature was seen supplying the right upper lobe. This was empirically embolised with particles which did not improve her symptoms. A subsequent CT-PA identified a pulmonary artery pseudoaneurysm in the cavity wall which was successfully embolised. There was no further haemoptysis and a repeat CT-PA 3 weeks later showed continuing occlusion of the pulmonary artery aneurysm. Investigations for tuberculosis were negative and she was discharged clinically well and on long-term antifungal therapy.