Aspergillosis

Revision as of 03:40, 28 December 2014 by Rossdonaldson1 (talk | contribs)

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