Aspergillosis: Difference between revisions
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==Background== | ==Background== | ||
* Primary affects lung | * Primary affects lung | ||
* Mold: Hyphae that branches 45° | * [[Mold]]: Hyphae that branches 45° | ||
* Inhalation | * Inhalation | ||
* 4 syndromes: | * 4 syndromes: | ||
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** Aspergilloma | ** Aspergilloma | ||
** Invasive aspergillosis | ** Invasive aspergillosis | ||
==Clinical Features== | ==Clinical Features== | ||
* Allergic Bronchopulmonary Aspergillosis (ABPA) | * Allergic Bronchopulmonary Aspergillosis (ABPA) | ||
** Hypersensitivity reaction to ''A fumigatus'' | ** Hypersensitivity reaction to ''A fumigatus'' | ||
** Asthma and cystic fibrosis | ** Asthma and cystic fibrosis | ||
** Cough, mucous plugs, bronchial casts, hemoptysis, wheezing | ** Cough, mucous plugs, bronchial casts, [[hemoptysis]], wheezing | ||
** +/- Allergic fungal sinusitis | ** +/- Allergic fungal sinusitis | ||
* Chronic Necrotizing Aspergillosis Pneumonia (CNPA) | * Chronic Necrotizing Aspergillosis Pneumonia (CNPA) | ||
** Underlying lung disease (steroid-dependent COPD, alcoholism) | ** Underlying lung disease (steroid-dependent [[COPD]], [[alcoholism]]) | ||
** Subacute pneumonia, resistant to antibiotics and cavitates | ** Subacute [[pneumonia]], resistant to [[antibiotics]] and cavitates | ||
** Fever, cough, night sweats, weight loss | ** [[Fever]], cough, night sweats, weight loss | ||
* Aspergilloma (Fungus ball) | * Aspergilloma (Fungus ball) | ||
** Preexisting cavitary lung disease (Tb, sarcoidosis) or cystic lesion (PCP) | ** Preexisting cavitary lung disease (Tb, sarcoidosis) or cystic lesion (PCP) | ||
** Hemoptysis, cough and fever | ** [[Hemoptysis]], cough and fever | ||
** Asymptomatic radiographic abnormality | ** Asymptomatic radiographic abnormality | ||
* Invasive aspergillosis | * Invasive aspergillosis | ||
** Neutropenia or immunosuppression | ** [[Neutropenia]] or immunosuppression | ||
** Organ transplantation (bone marrow), leukemia, lymphoma, chemotherapy | ** Organ transplantation (bone marrow), leukemia, lymphoma, chemotherapy | ||
** Long-term steroid use (ex COPD) | ** Long-term steroid use (ex [[COPD]]) | ||
** Fever, cough, dyspnea, pleuritic chest pain, hemoptysis | ** [[Fever]], cough, dyspnea, pleuritic [[chest pain]], [[hemoptysis]] | ||
** Rapidly progressive, can be fatal | ** Rapidly progressive, can be fatal | ||
* Can cause skin infection | * Can cause skin infection | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* Asthma, bronchiectasis, eosinophilia, pneumonia, ARDS | * [[Asthma]], bronchiectasis, [[eosinophilia]], [[pneumonia]], [[ARDS]] | ||
* Fungal or viral infection, PE, abscess, Tb, sarcoidosis | * Fungal or viral infection, [[PE]], [[abscess]], [[Tb]], [[sarcoidosis]] | ||
==Workup== | ==Workup== | ||
* ABPA | * ABPA | ||
** Eosinophilia | ** [[Eosinophilia]] | ||
** Skin test + for ''A. Fumigatus'' | ** Skin test + for ''A. Fumigatus'' | ||
** Serum IgE > 1000 IU/dL or > x 2-fold rise from baseline | ** Serum IgE > 1000 IU/dL or > x 2-fold rise from baseline | ||
| Line 43: | Line 46: | ||
* Aspergilloma | * Aspergilloma | ||
** Precipitin Ab test + | ** Precipitin Ab test + | ||
** CXR/CT: Mass in preexisting cavity, often in upper lobe (crescent of air outlining solid mass) | ** [[CXR]]/CT: Mass in preexisting cavity, often in upper lobe (crescent of air outlining solid mass) | ||
* Invasive apsergillosis and CNPA | * Invasive apsergillosis and CNPA | ||
** Visualization of fungi (Silver stain) | ** Visualization of fungi (Silver stain) | ||
| Line 50: | Line 53: | ||
** CXR: Nodules, cavitary lesions, alveolar infiltrates | ** CXR: Nodules, cavitary lesions, alveolar infiltrates | ||
** CT chest: Halo sign, screscent of air surrounding nodules, wedge-shaped or pleural-based infiltrates, cavitation, pulmonary infarction | ** CT chest: Halo sign, screscent of air surrounding nodules, wedge-shaped or pleural-based infiltrates, cavitation, pulmonary infarction | ||
==Management== | ==Management== | ||
* Pulmonary consult +/- ID consult | * Pulmonary consult +/- ID consult | ||
* ABPA: Oral corticosteroids | * ABPA: Oral corticosteroids | ||
** Recurrent chronic, add oral itraconazole +/- surgical resection of nasal polyp | ** Recurrent chronic, add oral [[itraconazole]] +/- surgical resection of nasal polyp | ||
* Aspergilloma | * Aspergilloma | ||
** Symptomatic (hemoptysis): Oral itraconazole | ** Symptomatic ([[hemoptysis]]): Oral [[itraconazole]] | ||
** Intracavitary CT-guided percutaneous catheter px for amphotericin | ** Intracavitary CT-guided percutaneous catheter px for [[amphotericin B]] | ||
** Surgical resection | ** Surgical resection | ||
** Bronchial artery embolization | ** Bronchial artery embolization | ||
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** Voriconazole, itraconazole, caspogungin, or amphotericin | ** Voriconazole, itraconazole, caspogungin, or amphotericin | ||
** Reduce immunosuppression | ** Reduce immunosuppression | ||
==Special Population: Cystic Fibrosis== | |||
==Special Population: [[Cystic Fibrosis]]== | |||
* Diagnosis: Clinical deterioration; IgE> 1000IU/mL or > 2-4x baseline; + serology; new infiltrate | * Diagnosis: Clinical deterioration; IgE> 1000IU/mL or > 2-4x baseline; + serology; new infiltrate | ||
* Treatment: New radiologic finding and sxs and change in baseline IgE >500 IU/mL | * Treatment: New radiologic finding and sxs and change in baseline IgE >500 IU/mL | ||
==Disposition== | ==Disposition== | ||
* Invasive aspergillosis often requires admission | * Invasive aspergillosis often requires admission | ||
* Admit if massive hemoptysis | * Admit if massive hemoptysis | ||
* ABPA usually managed outpatient | * ABPA usually managed outpatient | ||
==See Also== | ==See Also== | ||
*[[Fungal infections]] | |||
==External Links== | |||
*http://www.cdc.gov/fungal/diseases/aspergillosis/index.html?s_cid=cs_748 | *http://www.cdc.gov/fungal/diseases/aspergillosis/index.html?s_cid=cs_748 | ||
==Sources== | ==Sources== | ||
<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]] | |||
Revision as of 03:40, 28 December 2014
Background
- Primary affects lung
- Mold: Hyphae that branches 45°
- Inhalation
- 4 syndromes:
- Allergic Bronchopulmonary Aspergillosis (ABPA)
- Chronic Necrotizing Aspergillosis Pneumonia (CNPA)
- Aspergilloma
- Invasive aspergillosis
Clinical Features
- Allergic Bronchopulmonary Aspergillosis (ABPA)
- Hypersensitivity reaction to A fumigatus
- Asthma and cystic fibrosis
- Cough, mucous plugs, bronchial casts, hemoptysis, wheezing
- +/- Allergic fungal sinusitis
- Chronic Necrotizing Aspergillosis Pneumonia (CNPA)
- Underlying lung disease (steroid-dependent COPD, alcoholism)
- Subacute pneumonia, resistant to antibiotics and cavitates
- Fever, cough, night sweats, weight loss
- Aspergilloma (Fungus ball)
- 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
- Rapidly progressive, can be fatal
- Can cause skin infection
Differential Diagnosis
- Asthma, bronchiectasis, eosinophilia, pneumonia, ARDS
- Fungal or viral infection, PE, abscess, Tb, sarcoidosis
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
- Pulmonary consult +/- ID consult
- 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 B
- Surgical resection
- Bronchial artery embolization
- Invasive aspergillosis
- Voriconazole DOC
- Alternative: Posaconazole, amphotericin B, caspofungin
- Reduce immunosuppression
- CNPA
- Voriconazole, itraconazole, caspogungin, or amphotericin
- Reduce immunosuppression
Special Population: Cystic Fibrosis
- Diagnosis: Clinical deterioration; IgE> 1000IU/mL or > 2-4x baseline; + serology; new infiltrate
- Treatment: New radiologic finding and sxs and change in baseline IgE >500 IU/mL
Disposition
- Invasive aspergillosis often requires admission
- Admit if massive hemoptysis
- ABPA usually managed outpatient
See Also
External Links
Sources
- Harman EM, et al. (2014, May 31). Aspergillosis. eMedicine. Retrieved 12/24/2014 from http://emedicine.medscape.com/article/296052-overview