Aspergillosis: Difference between revisions
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==Background== | ==Background== | ||
* Primary affects lung | * Primary affects lung | ||
* Mold: Hyphae that branches 45° | |||
* Inhalation | |||
* 4 syndromes: | * 4 syndromes: | ||
** Allergic Bronchopulmonary Aspergillosis (ABPA) | ** Allergic Bronchopulmonary Aspergillosis (ABPA) | ||
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==Clinical Features== | ==Clinical Features== | ||
* Allergic Bronchopulmonary Aspergillosis (ABPA) | * Allergic Bronchopulmonary Aspergillosis (ABPA) | ||
** 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 | ||
* Chronic Necrotizing Aspergillosis Pneumonia (CNPA) | * Chronic Necrotizing Aspergillosis Pneumonia (CNPA) | ||
** Underlying 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 | * 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 | ||
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** 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 | |||
* Can cause skin infection | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* Asthma, bronchiectasis, eosinophilia, pneumonia, ARDS | |||
* 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 | ||
** Aspergillus precipitins + | ** Aspergillus precipitins + | ||
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** 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 | |||
* 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 | ||
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** Voriconazole, itraconazole, caspogungin, or amphotericin | ** Voriconazole, itraconazole, caspogungin, or amphotericin | ||
** 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 | |||
* Admit if massive hemoptysis | |||
* ABPA usually managed outpatient | |||
==See Also== | ==See Also== | ||
*http://www.cdc.gov/fungal/diseases/aspergillosis/index.html?s_cid=cs_748 | |||
==External Links== | ==External Links== | ||
Revision as of 06:44, 25 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
- 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