Aspergillosis: Difference between revisions

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==Background==
==Background==
* Primary affects lung
*Primary affects lung
* 4 syndromes:  
*[[Mold]]: Hyphae that branches 45°
** Allergic Bronchopulmonary Aspergillosis (ABPA)
*Inhalation
** Chronic Necrotizing Aspergillosis Pneumonia (CNPA)
 
** Aspergilloma
** Invasive aspergillosis
==Clinical Features==
==Clinical Features==
* Allergic Bronchopulmonary Aspergillosis (ABPA)
===Allergic Bronchopulmonary Aspergillosis (ABPA)===
** Asthma and cystic fibrosis
*Hypersensitivity reaction to ''A fumigatus''
** Cough, mucous plugs, bronchial casts, hemoptysis, wheezing
*[[Asthma]] and [[cystic fibrosis]]
** Can be accompanied with allergic fungal sinusitis
*[[Cough]], mucous plugs, bronchial casts, [[hemoptysis]], [[wheezing]]
* Chronic Necrotizing Aspergillosis Pneumonia (CNPA)
*+/- Allergic fungal sinusitis
** Underlying disease (steroid-dependent COPD, alcoholism)
===Chronic Necrotizing Aspergillosis Pneumonia (CNPA)===
** Subacute pneumonia, resistant to antibiotics and cavitates
*Underlying lung disease (steroid-dependent [[COPD]], [[alcoholism]])
** Fever, cough, night sweats, weight loss
*Subacute [[pneumonia]], resistant to [[antibiotics]] and cavitates
* Aspergilloma
*[[Fever]], cough, night sweats, weight loss
** Preexisting cavitary lung disease (Tb, sarcoidosis) or cystic lesion (PCP)
===Aspergilloma (Fungus ball)===
** Hemoptysis, cough and fever
*Preexisting cavitary lung disease (Tb, sarcoidosis) or cystic lesion (PCP)
** Asymptomatic radiographic abnormality
*[[Hemoptysis]], cough and fever
* Invasive aspergillosis
*Asymptomatic radiographic abnormality
** Neutropenia or immunosuppression
===Invasive aspergillosis===
** Organ transplantation (bone marrow), leukemia, lymphoma, chemotherapy
*[[Neutropenia]] or immunosuppression
** Long-term steroid use (ex COPD)
*Organ [[transplant complications|transplantation]] (bone marrow), [[leukemia]], [[lymphoma]], chemotherapy
** Fever, cough, dyspnea, pleuritic chest pain, hemoptysis
*Long-term steroid use (ex [[COPD]])
*[[Fever]], cough, dyspnea, pleuritic [[chest pain]], [[hemoptysis]]
*Rapidly progressive, can be fatal
*Can cause skin infection
 
==Differential Diagnosis==
==Differential Diagnosis==
*[[Asthma]]
*[[Bronchiectasis]]
*[[Eosinophilia]]
*[[ARDS]]
*[[PE]]
*[[Lung abscess]]
*[[Sarcoidosis]]
*[[Tb]]
{{Causes of pneumonia}}
==Evaluation==
*ABPA
**[[Eosinophilia]]
**Skin test + for ''A. Fumigatus''
**Serum IgE > 1000 IU/dL or > x 2-fold rise from baseline
**Aspergillus precipitins +
**Aspergillus radioallergosorbent assay test + and sputum culture
**[[CXR]]: Fleeting pulmonary infiltrates, mucoid impaction, central bronchiectasis
**CT chest: Bronchiectasis, lobulated masses that are mucus-filled dilate bronchi
*Aspergilloma
**Precipitin Ab test +
**[[CXR]]/CT: Mass in preexisting cavity, often in upper lobe (crescent of air outlining solid mass)
*Invasive aspergillosis and CNPA
**Visualization of fungi (Silver stain)
**Positive culture from sputum, needle biopsy, or BAL
**Galactomannan level
**[[CXR]]: Nodules, cavitary lesions, alveolar infiltrates
**CT chest: Halo sign, screscent of air surrounding nodules, wedge-shaped or pleural-based infiltrates, cavitation, pulmonary infarction
===Special Population: [[Cystic Fibrosis]]===
*Diagnosis: Clinical deterioration; IgE> 1000IU/mL or > 2-4x baseline; + serology; new infiltrate
*Treatment: New radiologic finding and symptoms and change in baseline IgE >500 IU/mL


==Workup==
* ABPA
** Eosinophilia
** Skin test + for A. Fumigatus
** Serum IgE > 1000 IU/dL or > x 2-fold rise from baseline
** Aspergillus precipitins +
** Aspergillus radioallergosorbent assay test + and sputum culture
** CXR: Fleeting pulmonary infiltrates, mucoid impaction, central bronchiectasis
** CT chest: Bronchiectasis, lobulated masses that are mucus-filled dilate bronchi
* Aspergilloma
** Precipitin Ab test +
** CXR/CT: Mass in preexisting cavity, often in upper lobe (crescent of air outlining solid mass)
* Invasive apsergillosis and CNPA
** Visualization of fungi (Silver stain)
** Positive culture from sputum, needle biopsy, or BAL
** Galactomannan level
** CXR: Nodules, cavitary lesions, alveolar infiltrates
** CT chest: Halo sign, screscent of air surrounding nodules, wedge-shaped or pleural-based infiltrates, cavitation, pulmonary infarction
==Management==
==Management==
* ABPA: Oral corticosteroids
*Pulmonary consult +/- ID consult
** Recurrent chronic, add oral itraconazole +/- surgical resection of nasal polyp
*ABPA: Oral [[corticosteroids]]
* Aspergilloma
**Recurrent chronic, add oral [[itraconazole]] +/- surgical resection of nasal polyp
** Symptomatic (hemoptysis): Oral itraconazole
*Aspergilloma
** Intracavitary CT-guided percutaneous catheter px for amphotericin  
**Symptomatic ([[hemoptysis]]): Oral [[itraconazole]]
** Surgical resection
**Intracavitary CT-guided percutaneous catheter px for [[amphotericin B]]
** Bronchial artery embolization
**Surgical resection
* Invasive aspergillosis
**Bronchial artery embolization
** Voriconazole DOC
*Invasive aspergillosis
** Alternative: Posaconazole, amphotericin B, caspofungin
**[[Voriconazole]] DOC
** Reduce immunosuppression
**Alternative: Posaconazole, [[amphotericin B]], [[caspofungin]]
* CNPA
**Reduce immunosuppression
** Voriconazole, itraconazole, caspogungin, or amphotericin
*CNPA
** Reduce immunosuppression
**[[Voriconazole]], [[itraconazole]], [[caspofungin]], or [[amphotericin b]]
**Reduce immunosuppression
 
==Disposition==
==Disposition==
*Invasive aspergillosis often requires admission
*Admit if massive hemoptysis
*ABPA usually managed outpatient


==See Also==
==See Also==
*[[Fungal infections]]
*[[Antifungals]]


==External Links==
==External Links==
*[http://www.cdc.gov/fungal/diseases/aspergillosis/index.html?s_cid=cs_748 CDC: Aspergillosis]


==Sources==
==References==
<references/>
<references/>
* Harman EM, et al. (2014, May 31). Aspergillosis. eMedicine. Retrieved 12/24/2014 from http://emedicine.medscape.com/article/296052-overview
*Harman EM, et al. (2014, May 31). Aspergillosis. eMedicine. Retrieved 12/24/2014 from http://emedicine.medscape.com/article/296052-overview
 
[[Category:ID]]

Latest revision as of 03:49, 8 March 2021

Background

  • Primary affects lung
  • Mold: Hyphae that branches 45°
  • Inhalation

Clinical Features

Allergic Bronchopulmonary Aspergillosis (ABPA)

Chronic Necrotizing Aspergillosis Pneumonia (CNPA)

Aspergilloma (Fungus ball)

  • Preexisting cavitary lung disease (Tb, sarcoidosis) or cystic lesion (PCP)
  • Hemoptysis, cough and fever
  • Asymptomatic radiographic abnormality

Invasive aspergillosis

Differential Diagnosis

Causes of Pneumonia

Bacteria

Viral

Fungal

Parasitic

Evaluation

  • ABPA
    • Eosinophilia
    • Skin test + for A. Fumigatus
    • Serum IgE > 1000 IU/dL or > x 2-fold rise from baseline
    • Aspergillus precipitins +
    • Aspergillus radioallergosorbent assay test + and sputum culture
    • CXR: Fleeting pulmonary infiltrates, mucoid impaction, central bronchiectasis
    • CT chest: Bronchiectasis, lobulated masses that are mucus-filled dilate bronchi
  • Aspergilloma
    • Precipitin Ab test +
    • CXR/CT: Mass in preexisting cavity, often in upper lobe (crescent of air outlining solid mass)
  • Invasive aspergillosis and CNPA
    • Visualization of fungi (Silver stain)
    • Positive culture from sputum, needle biopsy, or BAL
    • Galactomannan level
    • CXR: Nodules, cavitary lesions, alveolar infiltrates
    • CT chest: Halo sign, screscent of air surrounding nodules, wedge-shaped or pleural-based infiltrates, cavitation, pulmonary infarction

Special Population: Cystic Fibrosis

  • Diagnosis: Clinical deterioration; IgE> 1000IU/mL or > 2-4x baseline; + serology; new infiltrate
  • Treatment: New radiologic finding and symptoms and change in baseline IgE >500 IU/mL

Management

Disposition

  • Invasive aspergillosis often requires admission
  • Admit if massive hemoptysis
  • ABPA usually managed outpatient

See Also

External Links

References

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