Aspergillosis: Difference between revisions

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==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==

Revision as of 01:21, 7 April 2015

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)

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

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
  • 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