Difference between revisions of "Aspergillosis"

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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:
 
** Allergic Bronchopulmonary Aspergillosis (ABPA)
 
** Chronic Necrotizing Aspergillosis Pneumonia (CNPA)
 
** Aspergilloma
 
** 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)===
Line 25: Line 20:
 
===Invasive aspergillosis===
 
===Invasive aspergillosis===
 
*[[Neutropenia]] or immunosuppression
 
*[[Neutropenia]] or immunosuppression
*Organ transplantation (bone marrow), leukemia, lymphoma, chemotherapy
+
*Organ [[transplant complications|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]]
Line 32: Line 27:
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
* [[Asthma]]
+
*[[Asthma]]
*bronchiectasis
+
*[[Bronchiectasis]]
 
*[[Eosinophilia]]
 
*[[Eosinophilia]]
 
*[[ARDS]]
 
*[[ARDS]]
Line 43: Line 38:
 
{{Causes of pneumonia}}
 
{{Causes of pneumonia}}
  
==Diagnosis==
+
==Evaluation==
* 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
** Aspergillus precipitins +  
+
**Aspergillus precipitins +  
** Aspergillus radioallergosorbent assay test + and sputum culture
+
**Aspergillus radioallergosorbent assay test + and sputum culture
** CXR: Fleeting pulmonary infiltrates, mucoid impaction, central bronchiectasis
+
**[[CXR]]: Fleeting pulmonary infiltrates, mucoid impaction, central bronchiectasis
** CT chest: Bronchiectasis, lobulated masses that are mucus-filled dilate bronchi
+
**CT chest: Bronchiectasis, lobulated masses that are mucus-filled dilate bronchi
* 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 aspergillosis and CNPA
** Visualization of fungi (Silver stain)
+
**Visualization of fungi (Silver stain)
** Positive culture from sputum, needle biopsy, or BAL
+
**Positive culture from sputum, needle biopsy, or BAL
** Galactomannan level
+
**Galactomannan level
** 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
 +
 
 +
===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==
 
==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 B]]
+
**Intracavitary CT-guided percutaneous catheter px for [[amphotericin B]]
** Surgical resection
+
**Surgical resection
** Bronchial artery embolization
+
**Bronchial artery embolization
* Invasive aspergillosis
+
*Invasive aspergillosis
** Voriconazole DOC
+
**[[Voriconazole]] DOC
** Alternative: Posaconazole, amphotericin B, caspofungin
+
**Alternative: Posaconazole, [[amphotericin B]], [[caspofungin]]
** Reduce immunosuppression
+
**Reduce immunosuppression
* CNPA
+
*CNPA
** Voriconazole, itraconazole, caspogungin, or amphotericin
+
**[[Voriconazole]], [[itraconazole]], [[caspofungin]], or [[amphotericin b]]
** Reduce immunosuppression
+
**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==
 
==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==
Line 96: Line 91:
 
==References==
 
==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]]
 
[[Category:ID]]

Latest revision as of 20:31, 24 August 2019

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