Is It a New Pattern of Pulmonary Aspergillosis?

539 Is It a New Pattern of Pulmonary Aspergillosis? I read with great interest the article by Kang et al. [1]. The authors reported that in immunocompetent hosts who have no preexisting lesions of the lung, pulmonary aspergillosis might manifest on CT primarily as a single nodule or mass with or without an air crescent or as a localized consolidation. They termed the pattern “primary noninvasive pulmonary aspergillosis.” Unfortunately, the evidence that no preexisting underlying lesion was present is not clear in the article [1]. Did the authors draw that conclusion only because chest radiography or CT showed no other coexisting lesion? In that case, it should have been noted that diseases such as pneumonia, bronchial cyst, bulla, or lung abscess may show a single lesion, and patients who have aspergilloma that developed in such preexisting diseases may show no other lesion on radiologic studies. I think previous radiologic studies of the chest are essential to prove the absence of these preexisting diseases, but the authors did not mention previous studies. Previous CT scans showing no abnormality would be confirmatory evidence for the authors’ conclusion. However, previous chest radiographs do not afford a solid basis for their conclusion because frequently a small thinwalled bronchial cyst or bulla that is visible on chest CT is not observed on chest radiographs. As a basis for the new pattern of aspergillosis, the authors [1] presented a theory that the fungus might be implanted in a normal bronchus, which then gradually becomes dilated as a result of the pressure created by a growing colony [2]. The theory was originally from a French article [3]. I don’t know how such a conclusion was drawn in the study by Monod et al. because the article was not available. I presume that in 1957 when their article was published, chest radiographs obtained before the development of aspergilloma must have been the only way to determine the absence of preexisting abnormalities. However, chest radiographs with normal findings do not exclude small thin-walled cysts absolutely. Thus, the theory does not appear to be a reliable basis for defining primary noninvasive aspergillosis. Without evidence for the absence of preexisting diseases, the reported pathologic features [1] don’t appear different from secondary noninvasive aspergillosis. It is certain that the reported findings are unusual for secondary noninvasive pulmonary aspergillosis. The article would have been better if it had reported only unusual appearances of secondary noninvasive pulmonary aspergillosis. Yo Won Choi Hanyang University Hospital Seoul 133-792, South Korea