Chronic Pulmonary Aspergillosis

Epidemiology

  • Occurs in patients with severe underlying lung disease
  • Most cases have had modest degrees of immunosuppression: diabetics or chronic low-dose steroids
  • Predisposing Factors
    • Anti-TNF Therapy (see [[Anti-TNF Therapy]]): increased risk with infliximab

Etiology

  • xxx

Physiology

  • Locally invasive, slowly progressive Aspergillus infection

Pathology

  • xxx

Diagnosis

Sputum GS/Cult+Sens

  • Cultures positive for Aspergillus

FOB

  • BAL cultures positive for Aspergillus

CXR/Chest CT patterns:

  • Upper lobe cavitary infiltrates (unilateral or bilateral): resembles TB
    • Mycetoma may be present in one of the cavities
    • May extend to adjacent pleura

Serum Galactomannan

  • False-Positive
    • Cross-reactivity with other fungi
    • Gut translocation of galactomannan present in milk and cereals
    • Gut translocation of galactomannan with GVHD occurring after bone marrow transplant
    • Use of piperacillin/tazobactam (Zosyn) or amoxicillin/clavulanate (Augmentin)
  • False-Negative
    • Presence of anti-aspergillus antibodies
    • Localized or encapsulated infections
    • Use of antifungal therapy

Clinical

  • Pneumonia-like illness:

Treatment

  • Voriconazole: effective
  • Itraconazole: may be useful for mild-moderate cases or chronic suppression
    • IV itra is available (limit use to 2 wks to avoid cyclodextrin nephrtoxicity/avoid with CrCl <30 ml/min)
  • Ampho B: slows tissue destruction, but potential for cure is uncertain

References

  • xx