Aspergillosis

Background

• Primary affects lung
• 4 syndromes:
  • Allergic Bronchopulmonary Aspergillosis (ABPA)
  • Chronic Necrotizing Aspergillosis Pneumonia (CNPA)
  • Aspergilloma
  • Invasive aspergillosis

Clinical Features

• Allergic Bronchopulmonary Aspergillosis (ABPA)
  • Asthma and cystic fibrosis
  • Cough, mucous plugs, bronchial casts, hemoptysis, wheezing
  • Can be accompanied with allergic fungal sinusitis
• Chronic Necrotizing Aspergillosis Pneumonia (CNPA)
  • Underlying disease (steroid-dependent COPD, alcoholism)
  • Subacute pneumonia, resistant to antibiotics and cavitates
  • Fever, cough, night sweats, weight loss
• Aspergilloma
  • Preexisting cavitary lung disease (Tb, sarcoidosis) or cystic lesion (PCP)
  • Hemoptysis, cough and fever
  • Asymptomatic radiographic abnormality
• Invasive aspergillosis
  • Neutropenia or immunosuppression
  • Organ transplantation (bone marrow), leukemia, lymphoma, chemotherapy
  • Long-term steroid use (ex COPD)
  • Fever, cough, dyspnea, pleuritic chest pain, hemoptysis

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

• ABPA: Oral corticosteroids
  • Recurrent chronic, add oral itraconazole +/- surgical resection of nasal polyp
• Aspergilloma
  • Symptomatic (hemoptysis): Oral itraconazole
  • Intracavitary CT-guided percutaneous catheter px for amphotericin
  • Surgical resection
  • Bronchial artery embolization
• Invasive aspergillosis
  • Voriconazole DOC
  • Alternative: Posaconazole, amphotericin B, caspofungin
  • Reduce immunosuppression
• CNPA
  • Voriconazole, itraconazole, caspogungin, or amphotericin
  • Reduce immunosuppression

Sources

• Harman EM, et al. (2014, May 31). Aspergillosis. eMedicine. Retrieved 12/24/2014 from http://emedicine.medscape.com/article/296052-overview