Sinusitis in Patients with ABPA

When to suspect it, when to investigate, and when to refer

Why this matters

Patients with allergic bronchopulmonary aspergillosis (ABPA) are usually managed as having a lung disease. Diagnosis, monitoring, and treatment focus appropriately on the chest, immunology, and asthma control.

However, ABPA occurs within a single continuous airway, extending from the nose and sinuses to the lungs. Disease in the upper airway can coexist with, exacerbate, or complicate lower airway inflammation — yet sinus disease is not routinely assessed in ABPA care pathways.

This article outlines:

What is known about sinus disease in this context
Which symptoms should raise suspicion
When investigation or ENT referral should be considered
What GPs and non-specialists can reasonably do

The united airway: a brief reminder

The upper and lower airways share:

Type 2 (eosinophilic) inflammation
Immunoglobulin E–mediated immune responses
Common triggers, including allergens and fungi

Chronic rhinosinusitis is common in asthma and severe asthma, and treatment of sinus disease can improve lower airway outcomes in some patients.
ABPA sits within this same inflammatory spectrum, even though its management is lung-centred.

Sinus disease in ABPA: what is (and isn’t) known

What we know

Chronic rhinosinusitis is common in patients with asthma and severe asthma
Sinus disease may be symptomatic or relatively silent
ABPA guidelines do not mandate routine ENT review or sinus imaging
ENT involvement, therefore, varies widely between centres

What we do not know

Whether routine ENT assessment improves ABPA outcomes
Which ABPA patients benefit most from sinus intervention
The optimal timing for ENT referral in ABPA

As a result, clinical judgement remains central.

Symptoms that should prompt consideration of sinus disease

Sinusitis in ABPA patients does not always present with classic “blocked nose and facial pain”.
Key symptoms include:

Common but often overlooked

Persistent post-nasal drip
Foul, bitter, metallic, or “infected” taste in the mouth
Throat clearing, chronic cough
Thick or sticky mucus sensation
Symptoms are worse on waking or lying flat

More typical sinonasal features

Nasal blockage or congestion
Facial pressure or fullness
Reduced or altered sense of smell
Nasal crusting or discharge

Contextual clues

Poor durability of response to steroids or antifungals
Recurrent “flares” without clear chest triggers
Coexisting severe asthma or nasal polyps
Symptoms are worse in damp or mould-affected housing

A persistent foul taste in the mouth is a recognised symptom of chronic sinus disease, usually due to post-nasal drainage of inflamed secretions.

Damp homes and sinus disease

Living in damp or mould-affected environments is associated with:

Higher rates of chronic rhinosinusitis
Upper airway irritation and inflammation
Allergic sensitisation to fungal spores

In most cases, this results in inflammatory or allergic sinusitis, not invasive fungal infection.
Fungal involvement may act as an immune trigger, even when not labelled as “fungal sinusitis”.

Fungal sinusitis: rare vs under-recognised

It is important to distinguish between entities:

Type	Frequency	Key point
Invasive fungal sinusitis	Rare	Usually immunocompromised; dramatic presentation
Fungal ball (mycetoma)	Uncommon	Usually obvious on CT
Allergic fungal rhinosinusitis	Likely under-recognised	Requires active suspicion

Allergic fungal rhinosinusitis overlaps biologically with ABPA:

IgE-mediated
Eosinophilic inflammation
Thick allergic mucin

It is not routinely sought, so it may be under-diagnosed in at-risk groups.

What GPs and non-specialists can reasonably do

1. Take upper airway symptoms seriously

Especially in ABPA or severe asthma patients with:

Persistent post-nasal symptoms
Foul taste
Recurrent unexplained deterioration

2. Examine the nose and throat

Look for polyps, discharge, and crusting
Note mouth breathing or altered voice quality
Check dentition (to exclude dental causes)

3. Consider imaging when symptoms persist

CT sinuses (not plain X-ray) is the imaging of choice
Particularly appropriate if symptoms last >8–12 weeks or recur

4. Refer to ENT when:

Symptoms are persistent or progressive
CT shows significant sinus disease
There is a poor response to standard medical therapy
There is diagnostic uncertainty

Referral does not imply surgery — ENT input may be diagnostic or medical.

What this article is not saying

It does not suggest that all ABPA patients need an ENT referral
It does not claim that sinus treatment improves ABPA outcomes
It does not override existing guidelines

It does suggest that earlier consideration of the upper airway is reasonable in selected patients.

Key take-home points for clinicians

The airway functions as a single inflammatory system
Sinus disease may be subtle, under-reported, or atypical
A foul taste in the mouth is a meaningful symptom
Damp or mould exposure increases sinus disease risk
ENT referral is appropriate when symptoms persist or recur
Evidence gaps remain — but clinical vigilance is justified

In summary

ABPA is managed as a lung disease, but patients live with a whole airway.
Recognising when sinus disease may be contributing can help explain persistent symptoms and guide appropriate referral — without over-investigation or over-treatment.

by GAtherton

⭐ Aspergillus Bronchitis: The Overlooked Condition Hiding in Plain Sight

Estimated prevalence 1–2% in bronchiectasis and chronic airway disease clinics.

Aspergillus Bronchitis (AB) is a chronic, symptomatic infection of the airways caused by Aspergillus species in people with underlying lung disease. It sits between simple colonisation and chronic pulmonary aspergillosis (CPA), and is frequently overlooked or mislabelled as “recurrent infection,” “post-viral symptoms,” or uncontrolled bronchiectasis.

Unlike CPA, Aspergillus Bronchitis does not require cavities or major structural destruction — which makes it both easier to miss and surprisingly common among people with chronic airway disease.

When recognised and treated (usually with antifungal therapy for several months), symptoms often improve significantly. But because awareness remains low, most patients cycle through unnecessary antibiotics, repeated exacerbations, and worsening airway disease before the real cause is identified.

⭐ What Exactly Is Aspergillus Bronchitis?

Aspergillus Bronchitis is defined by:

chronic productive cough
sputum growing Aspergillus species repeatedly
airway inflammation
symptoms lasting over 3 months
underlying airway disease (bronchiectasis, CF, COPD, prior TB, ABPA)
response to antifungal therapy

Unlike ABPA:

there is no allergic response,
IgE is usually normal,
eosinophils are normal or mildly elevated.

Unlike CPA:

there are no cavities on imaging,
IgG may be normal or only slightly elevated,
disease is confined to the airways, not lung tissue.

This places AB in a “grey zone” — often invisible unless specifically looked for.

⭐ Why Aspergillus Bronchitis Is Missed

1. Symptoms mimic common chronic airway disease

Typical AB symptoms include:

daily productive cough
worsening sputum thickness
breathlessness
fatigue
repeated “chest infections”
slow-to-clear mucus
crackles or wheeze

These resemble:

bronchiectasis exacerbations
COPD flare-ups
chronic infection with Pseudomonas or NTM
post-viral cough
uncontrolled asthma

Without fungal awareness, clinicians default to bacterial explanations.

2. Sputum grows multiple organisms — Aspergillus is dismissed

In bronchiectasis, sputum frequently grows:

Haemophilus
Pseudomonas
Staphylococcus
Streptococcus
NTM

When Aspergillus appears, it’s often labelled:

“colonisation”
“contaminant”
“not clinically relevant”

But repeated isolation with persistent symptoms is highly suggestive of AB.

3. IgE/IgG results may be normal

Many clinicians expect high IgE or IgG to “confirm Aspergillus disease.”
But in Aspergillus Bronchitis:

IgE is usually normal
IgG can be normal or borderline

This leads to false reassurance.

4. Radiology rarely shows overt features

CT scans in AB may show:

mucus plugging
mild bronchial wall thickening
small nodules
progression of bronchiectasis

But they do not show the cavities of CPA or classic features of ABPA.

Therefore radiologists often report scans as “no significant change” or “stable bronchiectasis.”

5. Antibiotics appear to help — temporarily

Patients often improve slightly with:

amoxicillin
doxycycline
macrolides
ciprofloxacin

This gives clinicians the impression of bacterial disease, but symptoms soon return.

6. Lack of awareness

Many specialists (even in respiratory clinics) are unaware that Aspergillus Bronchitis:

exists as a distinct clinical entity
can be disabling
responds to antifungals
predicts progression to CPA if untreated

This leads to significant diagnostic delay.

⭐ Who Is at Highest Risk?

1. Bronchiectasis

The largest risk group.
Aspergillus Bronchitis may account for 1–2% of all bronchiectasis patients, and up to 5–10% in severe or frequent exacerbator groups.

2. Cystic Fibrosis (CF)

These patients frequently grow Aspergillus but not all have ABPA — some have Aspergillus Bronchitis.

3. COPD and chronic productive cough

Especially those with:

frequent mucus plugging
repeated “infective exacerbations”
progressive sputum production

4. Post-TB airway damage

Chronic airway deformity, scarring, and bronchiectasis from old TB predispose to fungal infection.

5. Post-COVID structural disease

A new and growing risk group, especially after prolonged ICU ventilation.

6. ABPA patients

Some patients develop Aspergillus Bronchitis during steroid-dominated treatment or after stopping antifungals.

⭐ Which Specialities Need Greater Awareness?

Respiratory medicine
(especially bronchiectasis clinicians and severe asthma teams)
Infectious Diseases
(frequent respiratory presentations with chronic airway infection)
Radiology
(to recognise subtle but progressive airway changes)
Primary care
(“recurrent chest infection” or “persistent cough” patients)
Physiotherapy & airway clearance teams
(excessive sputum with fungal elements)
Cystic Fibrosis services

The National Aspergillosis Centre is the ideal referral destination when diagnosis is uncertain or symptoms persist despite typical management.

⭐ Red Flags Suggesting Aspergillus Bronchitis

1. Chronic (>3 months) productive cough + repeated Aspergillus in sputum

Even 2 positive sputums in the right clinical context should raise suspicion.

2. Bronchiectasis patient not improving on repeated antibiotics

3. Thick, tenacious mucus with black, grey, or brown plugs

4. Worsening CT bronchiectasis or mucus plugging

5. Absence of features typical for ABPA (normal IgE, no fleeting infiltrates)

6. Asthma or COPD patient with new persistent sputum

7. Partial response to antibiotics but rapid relapse

8. Unexplained fatigue and breathlessness in someone with airway disease

⭐ The Cost of Missed Aspergillus Bronchitis

If AB is not recognised early, consequences include:

repeated exacerbations
accelerating bronchiectasis
long-term airway damage
chronic inflammation
steroid overuse
unnecessary antibiotics
repeated hospitalisations
progression to CPA in some patients

For health systems, missed diagnosis leads to:

higher admission rates
inappropriate long-term antibiotic use
avoidable CT scans and investigations
greater long-term burden of CPA

But antifungal therapy — when appropriately used — can offer marked symptom improvement and reduce exacerbation frequency.

⭐ Conclusion

Aspergillus Bronchitis is a distinct, treatable form of chronic airway disease seen in people with bronchiectasis, asthma, COPD, CF, and post-TB lung damage. Yet lack of awareness means many patients are repeatedly misdiagnosed with bacterial infections or unexplained chronic cough.

Recognising red flags, reviewing sputum results carefully, and considering antifungal therapy can dramatically improve outcomes. Early referral to specialist centres such as the National Aspergillosis Centre is recommended for complex cases or uncertain diagnosis.

Early identification prevents airway deterioration — and reduces the likelihood of progression to CPA.

by GAtherton

🌿 Aspergillosis in the Sinuses (Allergic Fungal Rhinosinusitis – AFRS)

It’s quite possible for Aspergillus to affect both the lungs and the sinuses.
The sinuses are small air-filled spaces behind the nose, eyes, and cheeks that normally drain mucus freely. When Aspergillus spores become trapped there, they can trigger an allergic or inflammatory reaction — rather like ABPA in the lungs.

This allergic form is called Allergic Fungal Rhinosinusitis (AFRS).
It isn’t a contagious infection — it’s an overreaction of the immune system to fungal spores. Over time, it can lead to thick mucus, nasal blockage, and sometimes nasal polyps.

🩵 Common symptoms

Persistent nasal congestion or blockage
Thick or sticky mucus (sometimes with brown or dark flecks)
Reduced or lost sense of smell
Facial pressure, pain, or fullness (especially around the eyes or cheeks)
Post-nasal drip (mucus running down the throat)
Fatigue or worsening asthma symptoms

🔬 Diagnosis

CT scan of the sinuses – shows thickened or blocked areas
Nasal endoscopy – a tiny camera used to look inside
Fungal culture or microscopy from mucus samples
Blood tests – sometimes show raised total IgE or Aspergillus-specific IgE

💊 Treatment

Topical nasal steroids (sprays or rinses) or short courses of oral steroids to reduce inflammation
Saline rinses to help keep the sinuses clear
ENT surgery if sinuses are blocked or filled with thick fungal debris
Antifungal medication in some cases, especially if fungal growth is confirmed

🌸 The Main Types of Aspergillus Sinus Disease

There are several recognised types of sinus aspergillosis. Most people with ABPA or asthma experience only the allergic form (AFRS).

1️⃣ Allergic Fungal Rhinosinusitis (AFRS)

Caused by an allergic reaction to Aspergillus
Leads to inflammation, thick mucus, and polyps
Non-invasive – the fungus stays on the surface
Managed with steroids, nasal rinses, and sometimes surgery
✅ This is the type most relevant for ABPA patients.

2️⃣ Fungal Ball (Mycetoma)

A clump of fungus (usually A. fumigatus) in a single sinus, often the cheek (maxillary) sinus
Common in otherwise healthy people
Causes chronic congestion or facial pain
Treated surgically – antifungals rarely needed
Not allergic and not invasive

3️⃣ Invasive Aspergillus Sinusitis

Rare, seen mostly in people with severely weakened immunity (e.g., chemotherapy, bone marrow transplant, uncontrolled diabetes)
The fungus invades surrounding tissue and blood vessels
Causes severe facial pain, swelling, fever, sometimes affecting the eyes
Needs urgent treatment with antifungal drugs and surgery
⚠️ Very rare in people with ABPA or CPA.

🤝 Specialist care

If you have lung aspergillosis (such as ABPA or CPA) and start noticing more nasal congestion, sinus pressure, or post-nasal drip, it’s sensible to mention it to your respiratory or mycology team.
At the National Aspergillosis Centre (NAC), sinus disease is often co-managed by ENT surgeons, respiratory physicians, and mycology specialists, ensuring coordinated care.

With the right combination of treatments — and early recognition of symptoms — most people find their sinus symptoms improve, and controlling sinus inflammation can even help with overall breathing and energy.

by GAtherton

Other forms of aspergillosis: Aspergillus Pneumonia (Community-Acquired Aspergillus Lung Infection)

What is it?

Aspergillus pneumonia is a rare but serious lung infection caused by breathing in spores of the Aspergillus mould (most often Aspergillus fumigatus). Unlike allergic conditions such as Allergic Bronchopulmonary Aspergillosis (ABPA) or Aspergillus bronchitis, which affect the airways, Aspergillus pneumonia occurs when the fungus actually invades lung tissue. This makes it a more dangerous condition.

How do people catch it?

Most cases are acquired in the community (outside hospital).
You may be at higher risk if you have:

A weakened immune system (chemotherapy, transplant, high-dose steroids, uncontrolled diabetes).
Chronic lung disease such as COPD or emphysema.
A very heavy exposure to fungal spores (compost heaps, rotting bark, mulch, or farming dust).

Almost all cases are due to Aspergillus fumigatus, though other species like A. flavus have also been reported.

How common is it?

Aspergillus pneumonia is uncommon, despite Aspergillus spores being everywhere in the environment.
It is most often seen in people with weak immune defences, long-term lung disease, or very high exposure.
Because it often looks like ordinary bacterial or viral pneumonia, it can be missed or diagnosed late.

Symptoms

The illness may start like a regular chest infection:

Cough (dry or with sputum)
Shortness of breath
Fever or chills
Chest pain
Fatigue
Sometimes coughing up blood

It may progress:

Slowly over weeks, with cavities (holes) forming in the lungs.
Very quickly, especially after flu, COVID-19, or high spore exposure.

How does it differ from other Aspergillus conditions?

Condition	What’s happening	Who gets it	Key signs
Aspergillus Pneumonia	Fungus invades lung tissue (serious infection)	Immunocompromised patients, COPD, heavy spore exposure	Pneumonia-like illness: fever, cough, breathlessness, chest pain
ABPA	Allergy to Aspergillus spores causes airway inflammation	People with asthma or cystic fibrosis	Wheeze, thick mucus plugs, recurrent asthma attacks
Aspergillus Bronchitis	Fungus grows in widened/damaged airways without invading tissue	People with bronchiectasis or chronic airway disease	Chronic cough, mucus, sometimes blood streaks

👉 In short:

Pneumonia = infection inside lung tissue (dangerous, urgent).
ABPA = allergic reaction in the lungs.
Bronchitis = long-term airway infection.

Is it a type of invasive aspergillosis?

Yes. Aspergillus pneumonia is considered a form of invasive aspergillosis because the fungus invades lung tissue:

Acute/severe form: fast, aggressive illness in very vulnerable people (immunocompromised, post-viral, heavy spore exposure).
Subacute or “necrotising” form: slower, smouldering infection in people with COPD, diabetes, or long-term steroids, often with cavities.

👉 It is not mild like ABPA or bronchitis — it requires antifungal treatment.

Diagnosis

Doctors may use:

Chest X-ray or CT scan – patches, cavities, or diffuse shadowing.
Sputum or bronchoscopy samples – to detect Aspergillus in culture or under the microscope.
Blood tests – for Aspergillus antibodies, or sometimes antigen (galactomannan).

Treatment

Antifungal medicines are the main treatment (voriconazole is most common; sometimes itraconazole or posaconazole).
Corticosteroids may be added in severe “pneumonitis-type” illness with overwhelming inflammation.

If treatment begins early, many people respond well. If diagnosis is delayed, the illness can progress rapidly and be life-threatening.

Outlook

Without antifungal treatment, Aspergillus pneumonia can be fatal.
With modern antifungal drugs, survival and recovery are possible.
Some people may develop long-term lung damage, even after successful treatment.

Key message for patients

If you have sudden worsening cough, fever, or chest symptoms that don’t improve with antibiotics — especially if you have COPD, are on steroids, or have had heavy spore exposure — ask your doctor whether Aspergillus pneumonia should be considered. Early diagnosis and treatment make the best outcomes possible.

by GAtherton

Other types of aspergillosis: Allergic Fungal Rhinosinusitis (AFRS)

(Also called Allergic Fungal Sinusitis, Allergic Aspergillus Sinusitis, Allergic Aspergillosis of the sinuses)

What is AFRS?

AFRS is a type of chronic sinus disease caused by an allergic reaction to fungi such as Aspergillus. It mainly affects adolescents and young adults, especially in warm and humid climates. AFRS accounts for about 5–10% of all cases of chronic sinusitis.

Unlike some other forms of fungal sinus disease, AFRS occurs in people with a normal immune system. It is not the same as an invasive fungal infection.

Symptoms

Common symptoms include:

Blocked or congested nose
Nasal polyps (soft swellings inside the nose)
Post-nasal drip (mucus running down the back of the throat)
Loss of smell or taste
Recurrent sinus infections
Headache or facial pressure

Pain is not typical — if severe pain is present, bacterial sinusitis may also be involved. Some people may have more dramatic problems such as worsening eye symptoms, changes in facial appearance, or very severe nasal blockage.

Diagnosis

Doctors may use a combination of:

CT scans showing thickened sinuses with “allergic mucin” (thick mucus mixed with fungal debris).
Nasal endoscopy to look for polyps and mucus.
Laboratory tests for raised IgE (allergy antibody) or specific IgE against fungi.
Biopsy or mucus samples, which sometimes show fungal filaments (though not always).

The diagnosis is sometimes difficult, as not every laboratory can reliably detect fungi in mucus.

Causes

AFRS is caused by an overactive immune response to fungi in the sinuses.

The most common fungi are Aspergillus (especially A. flavus), Alternaria, and Curvularia.
People with allergies, asthma, or nasal polyps are at higher risk.

Treatment

Treatment usually combines surgery and medical therapy.

Surgery: Performed using an endoscope through the nose. The aims are to:
1. Remove thick mucus and fungal debris.
2. Improve drainage and ventilation of the sinuses.
3. Allow future cleaning and access if disease comes back.
Steroids: Corticosteroids are used to control inflammation and prevent relapse. These may be:
- Tablets (short or long courses depending on severity)
- Nasal steroid sprays or rinses (usually long-term)
Other treatments:
- Antifungal medicines are not clearly proven to help but may be tried in some cases.
- Immunotherapy (allergy desensitisation) may help reduce recurrence.
- Antibiotics such as azithromycin are occasionally added if bacteria are thought to play a role.

Despite treatment, recurrence is common. Many patients need repeat surgery or ongoing medical therapy.

Link with ABPA (Allergic Bronchopulmonary Aspergillosis)

AFRS affects the sinuses, while ABPA affects the lungs, but both are caused by an allergic reaction to Aspergillus and have many similarities.

Some patients develop both AFRS and ABPA, sometimes called “sinobronchial allergic mycosis syndrome.”
If you have AFRS and also develop asthma, persistent cough, or changes on a lung scan, your doctor may check for ABPA.
Likewise, people with ABPA and severe sinus symptoms may be assessed for AFRS.
If there is concern, your doctors may refer you to the National Aspergillosis Centre (NAC) in Manchester for specialist advice.

Key points for patients

AFRS is not a dangerous invasive infection, but it is long-lasting and tends to come back.
Surgery plus steroid treatment is the main approach.
Ongoing follow-up is important because relapse is common.
AFRS and ABPA can sometimes occur together, so chest symptoms should always be discussed with your doctor.

by GAtherton

Other forms of aspergillosis: Chronic Aspergillus Sinusitis

(Chronic invasive and granulomatous forms)

Chronic sinus problems are very common, but in a small number of people they are caused by fungal infection, especially Aspergillus. This type of infection is different from the usual bacterial sinusitis and needs different treatment.

What is chronic Aspergillus sinusitis?

Chronic rhinosinusitis (CRS) is long-term inflammation of the sinuses (lasting more than 12 weeks).
In about 6–12% of CRS cases, fungi are the cause — with Aspergillus being the most common.
There are two important invasive forms that are rare but serious:
- Chronic invasive Aspergillus sinusitis – the fungus grows slowly into the lining of the sinuses and nearby tissues.
- Chronic granulomatous Aspergillus sinusitis – the immune system forms a hard granuloma (lump of immune cells and fungus), usually caused by Aspergillus flavus.

These conditions progress slowly but can cause long-term damage if not treated.

Who gets it?

Chronic invasive Aspergillus sinusitis is more common in Western countries and Japan.
Granulomatous sinusitis is more often seen in parts of Africa, South Asia (India, Pakistan), the Middle East, and occasionally the southern United States.
People at risk include:
- Those with diabetes, on long-term steroids, or with HIV infection.
- Sometimes people with no obvious immune problems can still develop it.
Aspergillus fumigatus usually causes chronic invasive sinusitis.
Aspergillus flavus is the main cause of granulomatous sinusitis.

Symptoms

Because these forms progress slowly, symptoms are often missed or mistaken for “ordinary sinus problems.” They may include:

Blocked or congested nose that doesn’t improve with usual treatments
Facial pain or pressure, especially around the eyes, cheeks, or forehead
Headaches
Nasal discharge, sometimes blood-stained
Bleeding from the nose (epistaxis)
Facial swelling or numbness
Bulging eye (proptosis) or reduced vision if the infection spreads to the orbit
Rarely: brain involvement (abscess, meningitis, stroke-like symptoms)

Granulomatous sinusitis often causes a slowly enlarging mass in the nose, cheek, or orbit, and may be mistaken for a tumour.

How is it diagnosed?

Scans (CT or MRI): show a mass in the sinuses, sometimes with bone damage. MRI is useful if the eye or brain are involved.
Endoscopy and biopsy: tissue samples are taken from the sinus lining.
Laboratory tests:
- Special stains and fungal culture help identify Aspergillus.
- Blood tests (Aspergillus IgG antibodies) can support the diagnosis.
Diagnosis can be delayed because the condition is uncommon and mimics other sinus problems.

Treatment

Prompt treatment is essential to prevent serious complications. Management usually involves:

Surgery
- To remove infected tissue and improve sinus drainage.
- Surgery also allows biopsy to confirm diagnosis.
Antifungal medication
- Long-term antifungal tablets (usually itraconazole or voriconazole).
- Sometimes intravenous antifungals (e.g. amphotericin B or posaconazole) are used in severe cases.
- Treatment usually lasts at least 6 months, often longer (sometimes up to a year).
Managing risk factors
- Good control of diabetes.
- Reducing or stopping steroid medicines if possible.

Outlook (prognosis)

With early diagnosis and combined treatment (surgery + antifungals), many patients do well.
Granulomatous sinusitis tends to relapse more often but generally has a better long-term outlook than invasive sinusitis.
Regular follow-up is essential because recurrence is common.
- Follow-up usually includes scans every few months and nasal endoscopy to check for regrowth.
- Ongoing monitoring may be needed for up to 5 years.

Key points for patients

Chronic Aspergillus sinusitis is rare, but important to recognise because it needs different treatment than ordinary sinus infections.
Symptoms can mimic chronic sinusitis or even cancer, so biopsy and specialist review are essential.
Surgery plus antifungal medication is the main treatment.
Long-term follow-up is needed to monitor for relapse.
If you have risk factors like diabetes or steroid use, controlling these is important.

✅ Summary:
Chronic invasive and granulomatous Aspergillus sinusitis are rare but serious fungal infections of the sinuses. They progress slowly, can cause damage to the eyes or brain if untreated, and are sometimes mistaken for tumours. With specialist care, surgery, antifungal therapy, and long-term follow-up, most patients can achieve good control of the disease.

by GAtherton

Other forms of aspergillosis: Aspergilloma (Fungal Ball in the Lung)

Aspergilloma (Fungal Ball in the Lung)

An aspergilloma is a clump of fungus (usually Aspergillus) that grows inside an old cavity in the lung. These cavities often form after conditions like tuberculosis (TB), other lung infections, or lung disease. The fungus does not usually invade healthy lung tissue, but it uses the cavity as a space to grow.

How common is aspergilloma?

Aspergillomas are uncommon overall, but they are more likely to appear in people who have had tuberculosis in the past.
In some countries where TB is (or was) common, aspergillomas are found quite frequently.
In countries like the UK, they are rare, but can still happen in people with conditions such as COPD, sarcoidosis, or after lung surgery.
Doctors often describe aspergilloma as part of the wider group of conditions called chronic pulmonary aspergillosis (CPA).

What are the symptoms?

Many people with an aspergilloma have very few symptoms at first – sometimes only a cough.
The most serious problem is bleeding from the lungs (haemoptysis). This can range from small streaks of blood in the sputum to heavy, life-threatening bleeding.
Some people may also have chest infections, breathlessness, or tiredness if other lung problems are present.

How is it found?

An aspergilloma usually shows up on a chest scan (X-ray or CT).
It often looks like a round “ball” inside a cavity in the upper part of the lung.
Sometimes it can move around a little inside the space.
Important note: Aspergillomas are not cancer, but they can sometimes be mistaken for cancer on scans. For this reason, doctors may arrange extra tests (such as blood tests, repeat scans, or sometimes biopsy) and may refer patients to the National Aspergillosis Centre (NAC) to be certain of the diagnosis.

Who looks after you?

At your local hospital, aspergillomas are usually managed by a respiratory (chest) specialist doctor.
Depending on your situation, they may also work with:
- Thoracic surgeons (for possible surgery)
- Radiologists (for scans or embolisation)
- Infectious diseases doctors (for antifungal treatment)
If your case is complex, unclear, or high-risk, your local team can refer you to the National Aspergillosis Centre (NAC) at Wythenshawe Hospital, Manchester. NAC is the UK’s only NHS specialist centre for aspergillosis and provides expert diagnosis, advanced testing, and treatment advice, often working alongside your local hospital team.

What is the outlook (prognosis)?

Some aspergillomas remain stable for years and cause very few problems.
A small number may even disappear on their own, although this is unusual.
The main risk is serious bleeding, which can be sudden. This is why regular check-ups are important.
Surgery to remove the part of lung with the aspergilloma is usually the most effective treatment and can be curative in suitable patients.
For people who cannot have surgery, treatments such as blocking bleeding vessels (embolisation) or instilling antifungal medicine into the cavity can sometimes help, but problems may return.

🚨 Emergency: If you cough up blood 🚨

Small streaks of blood (mild):
- Stay calm – these often stop by themselves.
- Contact your hospital team promptly to let them know.
- Keep a record of how much and how often it happens.
More than a few teaspoons, clots, or ongoing bleeding (moderate to heavy):
- Call 999 (UK) or go to A&E immediately.
- Sit upright to help protect the other lung.
- Take this leaflet or your aspergillosis care details with you.
Very heavy bleeding (life-threatening):
- Treat this as an emergency.
- Emergency doctors may use medicine to help blood clot, a procedure to block the bleeding vessel (embolisation), or surgery if possible.

⚠️ Always report any bleeding to your doctor, even if it seems small.

Treatment options

No treatment may be needed if the aspergilloma is small, not causing bleeding, and the person feels well. Regular monitoring is important.
Surgery is the most effective treatment if the fungal ball is causing repeated or heavy bleeding.
Antifungal tablets are sometimes used before or after surgery, but on their own they are usually not very effective.
Tranexamic acid – a medicine that helps the blood clot – is sometimes prescribed to reduce or control bleeding. It can be taken by mouth or given in hospital if bleeding is significant. It does not remove the aspergilloma but can help keep bleeding under control.
Other treatments for people who cannot have surgery include:
- Blocking the bleeding blood vessels (embolisation) – this can stop bleeding, but the effect may not last.
- Instilling antifungal medicine directly into the cavity – less common, results vary.

Key points for patients

An aspergilloma is not cancer, but because it can sometimes look like cancer on scans, careful checks and sometimes referral to the NAC are needed.
The main risk is bleeding, which may require urgent treatment.
Surgery offers the best chance of cure, but only if lung function allows.
If you have an aspergilloma, you should:
- Attend regular hospital check-ups.
- Report any coughing up of blood immediately.
- Take tranexamic acid if prescribed for bleeding, but also inform your doctor if bleeds occur.
- Avoid blood-thinning medicines (like aspirin, ibuprofen, or some herbal remedies) unless your doctor prescribes them.

by GAtherton