Definition
There are four major types of pulmonary aspergillosis: aspergilloma, chronic necrotizing aspergillosis, invasive pulmonary aspergillosis, and allergic bronchopulmonary aspergillosis (ABPA).
Aspergilloma
- Develops in a pre-existing lung cavity, most commonly from TB.
- Can be asymptomatic; if symptomatic, most common presentation is hemoptysis.
- Look for cavity with “fungus ball” on chest CT; fungus ball is gravity-dependent.
- Antifungal therapy not necessary if asymptomatic. If symptomatic, difficult to treat medically due to walled-off cavity and typically requires surgical resection.
Chronic Necrotizing Aspergillosis (Semi-Invasive Aspergillosis)
- Typically develops in moderately immunocompromised hosts (e.g., COPD/chronic lung disease on steroids).
- Progresses over months to years. CXR shows infiltrates in upper lobes or superior segments of lower lobes.
- Treat with voriconazole or IV lipid-based amphotericin.
Invasive Pulmonary Aspergillosis
- For details, see section ID: Invasive Aspergillosis.
- Develops in patients with BMT (32%), hematologic malignancy (29%), solid organ transplantation (9%), & HIV (8%).
- Presents with pleuritic chest pain and hemoptysis (from pulmonary infarction due to angioinvasive quality of Aspergillus).
- Initial evaluation: sputum fungal staining and culture, serum biomarkers including galactomannan assay and beta D-glucan (galactomannan more specific than beta-D-glucan).
- Chest CT shows multiple nodules, the “halo sign” (hemorrhage surrounding a nodule), the “crescent sign” (necrosis around a nodule), and pleural-based infiltrates.
- More invasive diagnostic modalities (e.g., BAL, transbronchial biopsy) may be necessary if diagnosis is not confirmed with initial testing.
- Treatment is difficult with high mortality. Use voriconazole and reverse underlying immunosuppression if possible.
Allergic Bronchopulmonary Aspergillosis (ABPA)
- A hypersensitivity reaction to Aspergillus antigens that develops most commonly in patients with asthma or in patients with cystic fibrosis.
- Usually presents with refractory wheezing, brown mucus plugs, pleuritic chest pain, fever, and eosinophilia.
- Skin prick testing is generally recommended for initial evaluation. If positive, look for elevated IgE (>1,000 ng/mL), presence of Aspergillus preciptins, fleeting upper-lobe infiltrates on CXR. Can lead to central bronchiectasis and pulmonary fibrosis.
- Treat with corticosteroids to suppress the immunologic response to Aspergillus antigens.
Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Thorax. 2015;70(3):270‐277. doi:10.1136/thoraxjnl-2014-206291
Patterson TF, Thompson G, Denning DW, Et. Al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 63, Issue 4, 15 August 2016, Pages e1–e60, https://doi.org/10.1093/cid/ciw326
Segal, BH, Walsh, TJ. Current approaches to diagnosis and treatment of invasive aspergillosis. Am J Respir Crit Care Med 2006;173:707
Soubani AO, Chandrasekar PH. The clinical spectrum of pulmonary aspergillosis. Chest 2002;121:1988-1999.