Fungal lung infection, aspergilloma and lung cavities
Understanding Chronic Pulmonary Aspergillosis
Chronic pulmonary aspergillosis is a group of slowly progressive lung conditions caused by Aspergillus mould. It most often develops in people with damaged or structurally abnormal lungs and can cause persistent cough, fatigue, weight loss, breathlessness and coughing up blood.
- Aspergillus mould
- Lung cavities
- Aspergilloma
- Aspergillus IgG
- Antifungal treatment
- Haemoptysis
CPA is not contagious
Aspergillosis is acquired from environmental exposure. It does not ordinarily spread from one person to another or from animals to people.
Diagnosis requires several pieces of evidence
Symptoms, progressive imaging abnormalities and evidence of Aspergillus infection or immune response are considered together, usually over at least three months.
What is chronic pulmonary aspergillosis?
CPA most commonly develops where previous disease has left lung cavities, scarring, emphysema or other structural abnormalities. Aspergillus may grow within an existing cavity, contribute to enlargement of cavities, form a fungal ball or drive progressive inflammation and fibrosis.
The condition can range from a stable isolated aspergilloma with few symptoms to progressive cavitary disease affecting large areas of lung.
CPA is a spectrum rather than one single presentation
The symptoms, imaging pattern, progression and treatment needs differ considerably between simple aspergilloma, chronic cavitary disease, Aspergillus nodules and chronic fibrosing disease.
The cause: Aspergillus mould
Aspergillus is a group of moulds found throughout the world. Aspergillus fumigatus is the species most commonly linked with CPA, although other species can occasionally cause disease.
Soil and compost
Aspergillus helps decompose organic matter and is commonly present in soil, compost heaps and piles of dead leaves.
Plants and decaying vegetation
Spores may be released from crops, rotting plants, bark, mulch and garden waste.
Dust and buildings
Spores can occur in household dust, damp buildings, building materials and disturbed construction dust.
Indoor air
Small numbers of airborne spores may be present indoors and in ventilation systems.
Outdoor air
Concentrations vary with weather, season, vegetation and local environmental disturbance.
Everyday exposure
Most people inhale Aspergillus spores regularly without developing disease.
Complete avoidance is rarely possible
Aspergillus is widespread. People with CPA should focus on clinically sensible exposure reduction rather than trying to create a completely mould-free environment.
How does Aspergillus lead to CPA?
Spores are inhaled
Microscopic airborne spores enter the respiratory tract during normal breathing.
Abnormal lung structure provides a site
Cavities, emphysema, fibrosis or damaged airways make fungal persistence more likely.
Aspergillus grows locally
Fungal material may line a cavity, form a fungal ball or contribute to chronic inflammation.
Lung damage may progress
Cavities can enlarge, new cavities may form and fibrosis can reduce functioning lung volume.
CPA often develops in people who are not profoundly immunocompromised. Instead, susceptibility frequently reflects a combination of damaged lung structure and subtle impairment in the local immune response.
CPA is different from invasive pulmonary aspergillosis
Invasive aspergillosis usually progresses rapidly in people with severe immune suppression or critical illness. CPA usually progresses more slowly and is associated with chronic structural lung disease.
Who is at risk of chronic pulmonary aspergillosis?
Previous tuberculosis
Residual lung cavities after pulmonary TB provide a recognised setting in which CPA or an aspergilloma can develop.
Non-tuberculous mycobacterial disease
NTM infection and CPA can coexist, creating diagnostic and treatment challenges.
COPD and emphysema
Bullae, damaged lung tissue and corticosteroid exposure may increase susceptibility.
Bronchiectasis
Chronically damaged and widened airways can coexist with Aspergillus sensitisation, colonisation or CPA.
Sarcoidosis
Fibrocavitary sarcoidosis is an important underlying condition associated with CPA.
Previous lung surgery or cancer
Surgery, radiotherapy and residual cavities may alter lung structure and create vulnerable areas.
Pneumothorax and bullous lung disease
Large bullae or previous pleural and lung damage may provide sites for fungal growth.
Mild immune impairment
Diabetes, malnutrition, older age and corticosteroid treatment may influence susceptibility or disease progression.
No obvious underlying cause
A minority of patients develop CPA without a clearly identified previous lung condition.
Patients with bronchiectasis can read more about bronchiectasis diagnosis and treatment .
Recognising the symptoms of CPA
Symptoms often develop gradually and may overlap with the underlying lung condition. Some people with a simple aspergilloma have few symptoms, while progressive cavitary disease can cause substantial illness.
Chronic cough
Cough may be dry or productive and may gradually become more troublesome.
Coughing up blood
Haemoptysis ranges from occasional blood-streaking to potentially life-threatening bleeding.
Weight loss
Reduced appetite and unexplained loss of weight may accompany progressive disease.
Fatigue
Persistent exhaustion may be disproportionate to activity and may not improve fully with rest.
Breathlessness
Breathlessness may reflect progression, fibrosis, underlying lung disease, anaemia or deconditioning.
Chest discomfort
Some people experience chest pain or discomfort, particularly when pleural disease is present.
Recurrent chest infections
Repeated episodes treated as bacterial infection may obscure an underlying chronic fungal problem.
Fever or sweats
Low-grade fever and night sweats may occur but are not present in every patient.
Reduced exercise capacity
Patients may notice a gradual decline in walking distance, stamina or ability to manage stairs.
Coughing up blood requires medical assessment
Seek urgent GP or NHS 111 advice for haemoptysis. Call 999 or attend A&E for more than a few streaks of blood, rapid or repeated bleeding, severe breathlessness, chest pain, dizziness or collapse.
Different forms of chronic pulmonary aspergillosis
| Form | Typical features | Important considerations |
|---|---|---|
| Simple aspergilloma | A single fungal ball within a stable pre-existing cavity, with little or no surrounding progression | May remain stable but can cause recurrent haemoptysis |
| Chronic cavitary pulmonary aspergillosis | One or more enlarging cavities, with or without fungal balls, pleural thickening or surrounding inflammation | The most common progressive form of CPA |
| Aspergillus nodules | One or more lung nodules that may resemble cancer, tuberculosis or another infection | Histology is often needed for definitive diagnosis |
| Chronic fibrosing pulmonary aspergillosis | Extensive fibrosis and lung destruction arising from progressive cavitary disease | May cause severe respiratory impairment |
| Subacute invasive aspergillosis | More rapidly progressive disease over weeks to a few months in mildly immunocompromised or debilitated patients | Sometimes grouped near the CPA spectrum but has evidence of tissue invasion and requires urgent treatment |
“Simple” refers to the disease pattern, not the patient experience
A simple aspergilloma can still cause significant or dangerous bleeding. Management depends on symptoms, lung function, operability and the stability of surrounding disease.
How is chronic pulmonary aspergillosis diagnosed?
Symptoms and history
Duration, haemoptysis, weight loss, previous TB, NTM, COPD and immune-modifying medicines are reviewed.
Chest imaging
CT assesses cavities, fungal balls, nodules, pleural thickening, fibrosis and progression over time.
Aspergillus testing
Aspergillus IgG, sputum culture, PCR, microscopy or tissue testing may support the diagnosis.
Exclude alternatives
Tuberculosis, NTM, bacterial infection, cancer and inflammatory disease may need investigation.
Tests used in CPA assessment
| Investigation | What it contributes | Important limitation |
|---|---|---|
| Chest CT | Defines cavities, fungal balls, nodules, fibrosis and disease progression | Imaging is suggestive but is not diagnostic by itself |
| Aspergillus IgG | Provides evidence of an immune response to Aspergillus and is an important CPA test | A negative result does not exclude every case or every Aspergillus species |
| Sputum fungal culture | May identify Aspergillus and permit susceptibility testing | Sensitivity is limited and a positive culture must be interpreted clinically |
| Aspergillus PCR | Detects fungal DNA in respiratory material | Availability and assay interpretation vary |
| Bronchoscopy | Obtains lower respiratory samples and assesses alternative diagnoses | It is invasive and not required in every patient |
| Biopsy | Can diagnose Aspergillus nodules and assess tissue invasion | Sampling risk must be balanced against likely benefit |
| Inflammatory markers and blood count | Assess inflammation, anaemia and general health | Results are non-specific |
| Lung-function testing | Measures respiratory impairment and provides a monitoring baseline | Does not identify the cause of structural abnormalities |
Lung function can be monitored through specialist lung-function testing .
Finding Aspergillus in sputum does not automatically prove CPA
Aspergillus can sometimes colonise damaged airways without causing progressive CPA. Results must be interpreted alongside symptoms, CT appearances, Aspergillus IgG and changes over time.
Conditions that can resemble or coexist with CPA
Tuberculosis
TB can cause cavities, weight loss, cough and haemoptysis and may also be the underlying cause of later CPA.
NTM lung disease
NTM infection can resemble CPA radiologically and both conditions may be present together.
Lung cancer
Aspergillus nodules, cavities and mass-like inflammation may resemble malignancy.
Bacterial lung abscess
Bacterial infection can cause cavities, fever and productive cough and may require urgent antimicrobial treatment.
Allergic bronchopulmonary aspergillosis
ABPA is an allergic airway condition usually associated with asthma or cystic fibrosis, rather than a chronic cavitary infection.
Invasive aspergillosis
Invasive disease progresses more rapidly and primarily affects severely immunocompromised or critically ill patients.
Treatment strategies for CPA
Observation
Selected patients with a stable, asymptomatic simple aspergilloma or nodule may be monitored rather than started on immediate long-term treatment.
Oral antifungal therapy
Long-term triazole treatment is commonly used for symptomatic or progressive chronic cavitary disease.
Surgery
Resection may be considered for carefully selected patients with localised disease, adequate lung reserve and significant haemoptysis.
Bronchial artery embolisation
Embolisation can control significant bleeding by blocking the abnormal blood vessel supplying the bleeding area.
Supportive respiratory care
Pulmonary rehabilitation, nutrition, airway clearance and optimisation of underlying lung disease may improve function.
Treating coexisting disease
TB, NTM, bacterial infection, bronchiectasis and COPD may need parallel treatment.
Surgery is not suitable for every patient
CPA often affects people with limited lung reserve or extensive bilateral disease. Surgical benefit must be balanced against bleeding, air leak, respiratory complications and loss of functioning lung tissue.
Antifungal medicines used for CPA
Oral triazole antifungals are the main medical treatments for many patients with symptomatic or progressive CPA. Choice depends on susceptibility, previous treatment, interactions, organ function, side effects and drug levels.
| Medicine | Possible role | Important monitoring issues |
|---|---|---|
| Itraconazole | Common first-line oral treatment when the isolate is susceptible and the medicine is tolerated | Drug levels, liver tests, interactions, absorption, fluid retention and cardiac effects |
| Voriconazole | Alternative when itraconazole is unsuitable, ineffective or not tolerated | Drug levels, liver tests, visual effects, skin photosensitivity, neurological effects and interactions |
| Posaconazole | May be used where first-line azoles fail, resistance is present or intolerance develops | Drug levels, liver tests, formulation, interactions and cardiac electrical effects |
| Isavuconazole | Specialist alternative for selected patients where other azoles are unsuitable | Liver tests, interactions, drug exposure and individual cardiac considerations |
| Intravenous amphotericin B | May be used for severe disease, azole resistance or failure of oral treatment | Kidney function, potassium, magnesium, blood count and infusion reactions |
| Intravenous echinocandin | A specialist option in selected refractory cases, commonly as a limited course | Liver tests, intravenous access and assessment of response |
Antifungals have many clinically important interactions
Azoles can interact with anticoagulants, statins, heart medicines, inhaled or oral corticosteroids, anti-epileptic drugs, immunosuppressants and many other treatments. Every prescription and supplement should be reviewed.
Treatment duration is individualised
Courses commonly last at least six months and are often longer. Some patients require prolonged or suppressive therapy when disease returns after treatment is stopped or cannot be fully controlled.
Managing haemoptysis in CPA
Bleeding can arise from fragile blood vessels around a cavity or aspergilloma. The amount may range from occasional streaking to a major medical emergency.
Clinical assessment
The amount, frequency, breathing impact, anticoagulant use and haemodynamic stability must be assessed.
CT angiography
Imaging may help identify the likely bleeding region and guide urgent intervention.
Tranexamic acid
It may be considered for selected bleeding episodes after assessment of risks, contraindications and severity.
Bronchial artery embolisation
Interventional radiology can block abnormal bronchial vessels and control significant haemoptysis.
Antifungal treatment
Controlling active CPA may reduce future bleeding risk, although improvement is not immediate.
Surgery
Resection may provide definitive treatment for selected patients with localised resectable disease.
Significant haemoptysis is an emergency
Call 999 for more than a few streaks of blood, rapid or ongoing bleeding, breathing difficulty, chest pain, dizziness, weakness or collapse. Do not drive yourself to hospital.
Regular monitoring during CPA treatment
Monitoring assesses whether treatment is controlling the disease, whether side effects are emerging and whether another condition is contributing to symptoms.
Symptoms and weight
Cough, haemoptysis, breathlessness, fatigue, appetite, weight and activity level are reviewed.
Liver and kidney tests
Blood tests monitor organ function and treatment toxicity.
Antifungal drug levels
Therapeutic drug monitoring helps confirm absorption and reduce the risks of under-treatment or toxicity.
Repeat imaging
Chest X-rays or CT scans assess cavity size, new lesions, fibrosis and fungal-ball changes.
Microbiology
Repeat sputum culture or molecular testing may identify persistent infection or emerging azole resistance.
Lung function
Spirometry and gas-transfer testing can track functional decline or stability.
Symptoms and scans may improve at different rates
Fatigue or appetite may improve before radiological change is obvious. Conversely, stable symptoms do not always guarantee that cavities or fibrosis have stopped progressing.
Living with chronic pulmonary aspergillosis
Pulmonary rehabilitation
Supervised exercise and education may improve stamina, confidence and breathlessness management.
Nutrition
Dietetic support may be helpful when poor appetite or weight loss is affecting strength and recovery.
Airway clearance
Physiotherapy may help when bronchiectasis and retained sputum coexist.
Vaccination
Influenza, COVID-19 and pneumococcal vaccination may be advised according to age, risk and current guidance.
Smoking cessation
Stopping smoking helps preserve remaining lung function and reduces wider respiratory and cardiovascular risk.
Exposure reduction
Avoiding intense compost, mould and construction-dust exposure may be sensible, particularly during active or severe disease.
Prognosis: is CPA a lifelong condition?
CPA is often a long-term condition, but its course varies. Some people have stable localised disease, while others experience progressive cavities, fibrosis, recurrent haemoptysis or reduced lung function.
Antifungal treatment can improve symptoms and stabilise disease, but relapse may occur after treatment stops. Long-term suppressive therapy may therefore be appropriate for selected patients.
Better outlook factors
Localised disease, preserved lung function, treatment tolerance and early recognition generally support better outcomes.
More complex disease
Bilateral cavitation, fibrosis, severe underlying lung disease and antifungal resistance can make control more difficult.
Individual follow-up
Prognosis depends on CPA subtype, lung reserve, other illnesses, treatment response and bleeding risk.
Remission and control are possible
Long-term does not mean untreatable. Many patients achieve meaningful symptom improvement and radiological stability with specialist treatment and regular monitoring.
When should you seek specialist help?
Arrange respiratory assessment when:
- a cough persists for more than three weeks;
- you have unexplained weight loss or fatigue;
- breathlessness or exercise tolerance is worsening;
- imaging shows a cavity, fungal ball or lung nodule;
- Aspergillus has repeatedly grown from sputum;
- you have previous TB, NTM, sarcoidosis or cavitary disease;
- current CPA treatment is not controlling symptoms.
Seek urgent help when:
- you cough up more than a few streaks of blood;
- bleeding is recurrent or increasing;
- breathing becomes suddenly difficult;
- you develop chest pain, dizziness or collapse;
- fever and respiratory symptoms worsen rapidly;
- you have a severe reaction to antifungal treatment.
Persistent or unusual respiratory infections can be assessed through the London Chest Specialist respiratory infection and chest infection service .
Frequently asked questions
Is chronic pulmonary aspergillosis contagious?
No. CPA is acquired from environmental Aspergillus spores and is not ordinarily passed from person to person.
Is an aspergilloma the same as CPA?
An aspergilloma is a fungal ball within a lung cavity. A simple aspergilloma is one form within the CPA spectrum, but CPA also includes progressive cavitary, nodular and fibrosing disease.
Does Aspergillus in sputum mean I have CPA?
Not necessarily. Aspergillus can colonise damaged airways. Diagnosis requires compatible symptoms, imaging and immunological or microbiological evidence considered together.
Can CPA be cured?
Localised disease may sometimes be removed surgically. Medical treatment more commonly aims for symptom improvement and long-term disease control rather than guaranteed eradication.
How long is antifungal treatment needed?
Treatment commonly continues for at least six months and is often longer. Some patients require prolonged suppressive therapy because disease returns when treatment stops.
Why are antifungal blood levels checked?
Absorption and metabolism vary substantially. Drug-level testing helps ensure adequate exposure while reducing the risk of toxicity.
Can CPA be mistaken for lung cancer or tuberculosis?
Yes. Cavities, nodules, weight loss and haemoptysis can occur in all three conditions. Microbiology, blood tests, serial imaging and sometimes biopsy are required.
Is surgery always needed for an aspergilloma?
No. Surgery is considered according to symptoms, bleeding, disease localisation, lung function and operative risk. Stable asymptomatic disease may be monitored.
Can CPA return after successful treatment?
Yes. Relapse can occur, particularly when structural lung abnormalities remain. Continued follow-up is therefore important.
When is coughing up blood an emergency?
Call 999 for more than a few streaks, ongoing or rapidly recurring bleeding, severe breathlessness, chest pain, dizziness, weakness or collapse.
Conclusion
Chronic pulmonary aspergillosis is a spectrum of long-term fungal lung disease that most commonly develops in structurally damaged lungs. Previous tuberculosis, NTM infection, COPD, bronchiectasis, sarcoidosis and fibrocavitary lung disease are important underlying conditions.
Symptoms may include persistent cough, haemoptysis, fatigue, breathlessness, weight loss and declining exercise tolerance. Because these symptoms overlap with tuberculosis, bacterial infection and lung cancer, CPA cannot be diagnosed from symptoms or a single test alone.
Diagnosis combines the clinical course, serial chest imaging, Aspergillus IgG and microbiological or tissue evidence while excluding alternative causes. The findings generally need to be present or progressive over at least three months.
Long-term antifungal therapy is central to treating symptomatic or progressive disease. Surgery, bronchial artery embolisation, respiratory rehabilitation, nutritional support and management of underlying lung disease have important roles in selected patients.
Specialist review is particularly important when the diagnosis is uncertain, treatment is poorly tolerated, antifungal resistance is suspected, disease is progressing or haemoptysis occurs.
References and further information
- NHS. Aspergillosis. Read NHS patient information
- National Aspergillosis Centre, Manchester University NHS Foundation Trust. Chronic pulmonary aspergillosis. Read the National Aspergillosis Centre guide
- Denning DW, Cadranel J, Beigelman-Aubry C, et al. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. View the European clinical guideline
- British Society for Medical Mycology. Best-practice recommendations for diagnosis of serious fungal diseases: 2025 update. View the UK diagnostic recommendations
- NHS England. Chronic pulmonary aspergillosis service specification for adults. View the NHS England service specification
- London Chest Specialist. Bronchiectasis diagnosis and treatment. Read about bronchiectasis
- London Chest Specialist. Lung-function testing. Read about lung-function tests
- London Chest Specialist. Chest infection diagnosis and treatment. Explore the respiratory infection service
Concerned About CPA or an Aspergilloma?
Specialist respiratory assessment can review your symptoms, previous lung disease, chest imaging, Aspergillus blood tests, sputum results and current antifungal treatment.
