Aspergillosis

Background

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

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
• ARDS
• PE
• Lung abscess
• Sarcoidosis
• Tb

Causes of Pneumonia

Bacteria

• Gram-positive
  • Streptococcus pneumoniae
  • Staphylococcus aureus
• Gram-negative
  • Haemophilus influenzae
  • Klebsiella pneumoniae
  • Escherichia coli
  • Pseudomonas aeruginosa
  • Moraxella catarrhalis
• Atypical pneumonia
  • Chlamydophila pneumoniae
  • Chlamydophila psittaci
  • Mycoplasma pneumoniae
  • Coxiella burnetti
  • Legionella pneumophila

Viral

• Common
  • Influenza
  • Respiratory syncytial virus
  • Parainfluenza
• Rarer
  • Adenovirus
  • Metapneumovirus
  • Severe acute respiratory syndrome (SARS)
  • Middle east respiratory syndrome coronavirus (MERS)
• Cause other diseases, but sometimes cause pneumonia
  • Herpes simplex virus
  • Varicella-zoster (VZV)
  • Measles
  • Rubella
  • Cytomegalovirus
  • Smallpox
  • Dengue

Fungal

• Histoplasmosis
• Coccidioidomycosis
• Blastomycosis
• Pneumocystis jirovecii pneumonia (PCP)
• Sporotrichosis
• Cryptococcosis
• Aspergillosis
• Candidiasis

Parasitic

• Ascariasis
• Schistosomiasis
• Toxoplasma gondii

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 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 symptoms and change in baseline IgE >500 IU/mL

Disposition

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

See Also

• Fungal infections

External Links

• http://www.cdc.gov/fungal/diseases/aspergillosis/index.html?s_cid=cs_748

References

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

Authors

Ami Yamamoto, Ross Donaldson, Neil Young, Yos Yachivev