Aspergillosis: Difference between revisions
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==Background== | ==Background== | ||
* Primary affects lung | *Primary affects lung | ||
* [[Mold]]: Hyphae that branches 45° | *[[Mold]]: Hyphae that branches 45° | ||
* Inhalation | *Inhalation | ||
==Clinical Features== | ==Clinical Features== | ||
===Allergic Bronchopulmonary Aspergillosis (ABPA)=== | ===Allergic Bronchopulmonary Aspergillosis (ABPA)=== | ||
*Hypersensitivity reaction to ''A fumigatus'' | *Hypersensitivity reaction to ''A fumigatus'' | ||
*Asthma and cystic fibrosis | *[[Asthma]] and [[cystic fibrosis]] | ||
*Cough, mucous plugs, bronchial casts, [[hemoptysis]], wheezing | *[[Cough]], mucous plugs, bronchial casts, [[hemoptysis]], [[wheezing]] | ||
*+/- Allergic fungal sinusitis | *+/- Allergic fungal sinusitis | ||
===Chronic Necrotizing Aspergillosis Pneumonia (CNPA)=== | ===Chronic Necrotizing Aspergillosis Pneumonia (CNPA)=== | ||
| Line 25: | Line 20: | ||
===Invasive aspergillosis=== | ===Invasive aspergillosis=== | ||
*[[Neutropenia]] or immunosuppression | *[[Neutropenia]] or immunosuppression | ||
*Organ transplantation (bone marrow), leukemia, lymphoma, chemotherapy | *Organ [[transplant complications|transplantation]] (bone marrow), [[leukemia]], [[lymphoma]], chemotherapy | ||
*Long-term steroid use (ex [[COPD]]) | *Long-term steroid use (ex [[COPD]]) | ||
*[[Fever]], cough, dyspnea, pleuritic [[chest pain]], [[hemoptysis]] | *[[Fever]], cough, dyspnea, pleuritic [[chest pain]], [[hemoptysis]] | ||
| Line 32: | Line 27: | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* [[Asthma]] | *[[Asthma]] | ||
* | *[[Bronchiectasis]] | ||
*[[Eosinophilia]] | *[[Eosinophilia]] | ||
*[[ARDS]] | *[[ARDS]] | ||
| Line 43: | Line 38: | ||
{{Causes of pneumonia}} | {{Causes of pneumonia}} | ||
== | ==Evaluation== | ||
* ABPA | *ABPA | ||
** [[Eosinophilia]] | **[[Eosinophilia]] | ||
** Skin test + for ''A. Fumigatus'' | **Skin test + for ''A. Fumigatus'' | ||
** Serum IgE > 1000 IU/dL or > x 2-fold rise from baseline | **Serum IgE > 1000 IU/dL or > x 2-fold rise from baseline | ||
** Aspergillus precipitins + | **Aspergillus precipitins + | ||
** Aspergillus radioallergosorbent assay test + and sputum culture | **Aspergillus radioallergosorbent assay test + and sputum culture | ||
** CXR: Fleeting pulmonary infiltrates, mucoid impaction, central bronchiectasis | **[[CXR]]: Fleeting pulmonary infiltrates, mucoid impaction, central bronchiectasis | ||
** CT chest: Bronchiectasis, lobulated masses that are mucus-filled dilate bronchi | **CT chest: Bronchiectasis, lobulated masses that are mucus-filled dilate bronchi | ||
* Aspergilloma | *Aspergilloma | ||
** Precipitin Ab test + | **Precipitin Ab test + | ||
** [[CXR]]/CT: Mass in preexisting cavity, often in upper lobe (crescent of air outlining solid mass) | **[[CXR]]/CT: Mass in preexisting cavity, often in upper lobe (crescent of air outlining solid mass) | ||
* Invasive | *Invasive aspergillosis and CNPA | ||
** Visualization of fungi (Silver stain) | **Visualization of fungi (Silver stain) | ||
** Positive culture from sputum, needle biopsy, or BAL | **Positive culture from sputum, needle biopsy, or BAL | ||
** Galactomannan level | **Galactomannan level | ||
** CXR: Nodules, cavitary lesions, alveolar infiltrates | **[[CXR]]: Nodules, cavitary lesions, alveolar infiltrates | ||
** CT chest: Halo sign, screscent of air surrounding nodules, wedge-shaped or pleural-based infiltrates, cavitation, pulmonary infarction | **CT chest: Halo sign, screscent of air surrounding nodules, wedge-shaped or pleural-based infiltrates, cavitation, pulmonary infarction | ||
===Special Population: [[Cystic Fibrosis]]=== | |||
*Diagnosis: Clinical deterioration; IgE> 1000IU/mL or > 2-4x baseline; + serology; new infiltrate | |||
*Treatment: New radiologic finding and symptoms and change in baseline IgE >500 IU/mL | |||
==Management== | ==Management== | ||
* Pulmonary consult +/- ID consult | *Pulmonary consult +/- ID consult | ||
* ABPA: Oral corticosteroids | *ABPA: Oral [[corticosteroids]] | ||
** Recurrent chronic, add oral [[itraconazole]] +/- surgical resection of nasal polyp | **Recurrent chronic, add oral [[itraconazole]] +/- surgical resection of nasal polyp | ||
* Aspergilloma | *Aspergilloma | ||
** Symptomatic ([[hemoptysis]]): Oral [[itraconazole]] | **Symptomatic ([[hemoptysis]]): Oral [[itraconazole]] | ||
** Intracavitary CT-guided percutaneous catheter px for [[amphotericin B]] | **Intracavitary CT-guided percutaneous catheter px for [[amphotericin B]] | ||
** Surgical resection | **Surgical resection | ||
** Bronchial artery embolization | **Bronchial artery embolization | ||
* Invasive aspergillosis | *Invasive aspergillosis | ||
** Voriconazole DOC | **[[Voriconazole]] DOC | ||
** Alternative: Posaconazole, amphotericin B, caspofungin | **Alternative: Posaconazole, [[amphotericin B]], [[caspofungin]] | ||
** Reduce immunosuppression | **Reduce immunosuppression | ||
* CNPA | *CNPA | ||
** Voriconazole, itraconazole, | **[[Voriconazole]], [[itraconazole]], [[caspofungin]], or [[amphotericin b]] | ||
**Reduce immunosuppression | |||
* | |||
* | |||
==Disposition== | ==Disposition== | ||
* Invasive aspergillosis often requires admission | *Invasive aspergillosis often requires admission | ||
* Admit if massive hemoptysis | *Admit if massive hemoptysis | ||
* ABPA usually managed outpatient | *ABPA usually managed outpatient | ||
==See Also== | ==See Also== | ||
*[[Fungal infections]] | *[[Fungal infections]] | ||
*[[Antifungals]] | |||
==External Links== | ==External Links== | ||
*http://www.cdc.gov/fungal/diseases/aspergillosis/index.html?s_cid=cs_748 | *[http://www.cdc.gov/fungal/diseases/aspergillosis/index.html?s_cid=cs_748 CDC: Aspergillosis] | ||
==References== | ==References== | ||
<references/> | <references/> | ||
* Harman EM, et al. (2014, May 31). Aspergillosis. eMedicine. Retrieved 12/24/2014 from http://emedicine.medscape.com/article/296052-overview | *Harman EM, et al. (2014, May 31). Aspergillosis. eMedicine. Retrieved 12/24/2014 from http://emedicine.medscape.com/article/296052-overview | ||
[[Category:ID]] | [[Category:ID]] | ||
Latest revision as of 03:49, 8 March 2021
Background
- Primary affects lung
- Mold: Hyphae that branches 45°
- Inhalation
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)
- Underlying lung disease (steroid-dependent COPD, alcoholism)
- Subacute pneumonia, resistant to antibiotics and cavitates
- Fever, cough, night sweats, weight loss
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
Causes of Pneumonia
Bacteria
Viral
- Common
- Influenza
- Respiratory syncytial virus
- Parainfluenza
- Rarer
- Adenovirus
- Metapneumovirus
- Severe acute respiratory syndrome (SARS)
- Middle east respiratory syndrome coronavirus (MERS)
- 2019-nCoV (COVID-19)
- Cause other diseases, but sometimes cause pneumonia
Fungal
- Histoplasmosis
- Coccidioidomycosis
- Blastomycosis
- Pneumocystis jirovecii pneumonia (PCP)
- Sporotrichosis
- Cryptococcosis
- Aspergillosis
- Candidiasis
Parasitic
Evaluation
- 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 aspergillosis 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
Special Population: Cystic Fibrosis
- Diagnosis: Clinical deterioration; IgE> 1000IU/mL or > 2-4x baseline; + serology; new infiltrate
- Treatment: New radiologic finding and symptoms and change in baseline IgE >500 IU/mL
Management
- Pulmonary consult +/- ID consult
- ABPA: Oral corticosteroids
- Recurrent chronic, add oral itraconazole +/- surgical resection of nasal polyp
- Aspergilloma
- Symptomatic (hemoptysis): Oral itraconazole
- Intracavitary CT-guided percutaneous catheter px for amphotericin B
- Surgical resection
- Bronchial artery embolization
- Invasive aspergillosis
- Voriconazole DOC
- Alternative: Posaconazole, amphotericin B, caspofungin
- Reduce immunosuppression
- CNPA
- Voriconazole, itraconazole, caspofungin, or amphotericin b
- Reduce immunosuppression
Disposition
- Invasive aspergillosis often requires admission
- Admit if massive hemoptysis
- ABPA usually managed outpatient
See Also
External Links
References
- Harman EM, et al. (2014, May 31). Aspergillosis. eMedicine. Retrieved 12/24/2014 from http://emedicine.medscape.com/article/296052-overview