Invasive aspergillosis (IA) is caused by filamentous fungi of the Aspergillus species, which are found ubiquitously in soil. Inhalation of the aerosolised conidia (spores) causes the infection.
Mostly affects immunocompromised patients (e.g., stem cell transplant recipients, prolonged severe neutropenia, immunosuppressive therapy). It is rare in immunocompetent hosts.
Clinical findings are non-specific and include fever, cough, and pleuritic pain. High index of suspicion is required for early diagnosis. Lungs, sinuses, brain, and skin are sites of involvement.
High-resolution computer tomography (CT) scan and serum Aspergillus galactomannan antigen test are useful tests for early diagnosis.
Isavuconazole and voriconazole are the antifungal agents of choice. Lipid-based formulations of amphotericin B are an alternative.
Early diagnosis and therapy significantly improve prognosis of patients with IA.
Aspergilloma forms in pre-formed lung cavities. It is usually asymptomatic. Diagnosis is generally made by chest x-ray or CT scan. Antifungal drugs have been shown not to be beneficial. Surgery may be required in patients with severe haemoptysis.
Filamentous fungi of the Aspergillus species are ubiquitously found as soil inhabitants. Inhalation of the aerosolised conidia (spores) causes the infection. The clinical spectrum varies from colonisation, allergy (e.g., allergic bronchopulmonary aspergillosis), asthma, or aspergilloma (fungal ball) to invasive disease, depending on host immune impairment. Neutropenia and compromised T-lymphocyte/macrophage function are key immune deficiencies predisposing to tissue invasion.
This topic covers invasive aspergillosis and aspergilloma. Allergic bronchopulmonary aspergillosis is covered elsewhere.
History and exam
Key diagnostic factors
- presence of risk factors
- pleuritic chest pain
- pleural rub
- nasal ulcer
- skin rash
Other diagnostic factors
- congestion or sinus tenderness
- facial pain
- altered mental status
- cranial nerve palsy
- weight loss
- allogeneic stem cell transplantation
- prolonged severe neutropenia (>10 days)
- immunosuppressive therapy
- chronic granulomatous disease (CGD)
- solid organ transplantation (SOT)
- acute leukaemia
- aplastic anaemia
- pre-existing cavity (aspergilloma)
- advanced chronic lung disease
- influenza infection
- primary immunodeficiency
- HIV infection
- diabetes mellitus
- cystic fibrosis
- severe burns
- multiple myeloma
- immunocompetent patients
- age >55 years
1st investigations to order
- high-resolution chest CT scan
- high-resolution sinuses CT scan
- high-resolution brain CT scan
- MRI sinuses
- MRI brain
- serum Aspergillus galactomannan (GM) antigen by enzyme immunoassay (EIA)
- sputum culture
- sputum smear
Investigations to consider
- BAL Aspergillus galactomannan (GM) antigen
- bronchoscopy with bronchoalveolar lavage (BAL) fungal stain
- bronchoscopy with BAL fungal culture
- polymerase chain reaction
- serum (1-3)-beta-D-glucan
- serum IgG
- tissue biopsy
- tissue fungal culture
- tissue fungal stain
suspected invasive aspergillosis
confirmed invasive aspergillosis
prior invasive aspergillosis: prophylactic therapy
- Mucormycosis and other zygomycoses (e.g., phycomycosis, basidiobolomycosis)
- Microbiological laboratory testing in the diagnosis of fungal infections in pulmonary and critical care practice
- Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline
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