06. Pulmonary Aspergillosis

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.

 

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