Pulmonary Aspergilloma Presenting With Recurrent and Massive Hemoptysis in Post Tuberculous Cavities A Five Patient Surgical Case Series From a Tuberculosis Endemic Region

<title>Abstract</title> <p>Background Pulmonary aspergilloma is a localized manifestation of chronic pulmonary aspergillosis (CPA) that develops within pre-existing pulmonary cavities, most commonly following pulmonary tuberculosis (TB). Hemoptysis remains the most frequent and potentially life-threatening presentation. Surgical resection is considered the definitive treatment for localized disease, although management remains challenging because of dense pleural adhesions, distorted hilar anatomy, and impaired pulmonary reserve in post-tuberculous lungs. We report our experience managing five patients with symptomatic pulmonary aspergilloma at a tertiary referral center in South India. Case Presentation Five consecutive patients with symptomatic pulmonary aspergilloma were managed between March and May 2025. All patients had a previous history of pulmonary tuberculosis and presented with recurrent or massive hemoptysis. Computed tomography demonstrated intracavitary fungal masses within residual post-tuberculous cavities. Four patients underwent elective lobectomy, while one patient presenting with life-threatening hemoptysis underwent emergency pulmonary artery embolization followed by definitive lobectomy. Histopathological examination confirmed aspergilloma in all resected specimens, demonstrating septate fungal hyphae with acute-angle branching. Postoperative complications included prolonged air leak in one patient and empyema in another, both managed conservatively. There was no perioperative mortality and no recurrence of hemoptysis during follow-up. Conclusions Pulmonary aspergilloma remains an important cause of recurrent and massive hemoptysis in patients with previous tuberculosis. Surgical resection offers definitive treatment for localized disease with acceptable morbidity when performed in experienced centers. Endovascular embolization is an effective bridge to surgery in patients presenting with life-threatening hemorrhage. Early diagnosis and multidisciplinary management are critical for achieving favorable outcomes.</p>