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
** Can be accompanied with allergic fungal sinusitis
** +/- 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