Updated: 6/19/2019

Aspergillosis

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Snapshot
  • A 47-year-old man presents to the emergency room with 2 months of fevers, cough, and night sweats. He also reports having hemoptysis. His past medical history of significant for tuberculosis which was adequately treated 2 years ago. He recently tested negative for tuberculosis during routine testing for work which is in the healthcare industry. A chest radiograph shows a cavitary lesion in the left upper lobe. A CT scan further demonstrates a round mobile mass. Fine needle aspiration reveals fungal hyphae along with inflammatory cells. (Aspergilloma)
Introduction
  • Classification
    • Aspergillus species
      • Aspergillus fumigatus most commonly causes disease in humans
      • monomorphic fungus with septate hyphae that branch at acute angles (45 degrees)
      • clinical syndromes
        • invasive aspergillosis 
          • invasive infection of the lung
          • seen in neutropenic and other immunocompromised patients
        • aspergilloma
          • mycetoma (“fungal ball”) in pre-existing cavity
          • non-invasive
        • allergic bronchopulmonary aspergillosis (ABPA)
          • hypersensitivity reaction in patients with cystic fibrosis or asthma
          • causes bronchiectasis and eosinophilia
          • non-invasive
      • found in soil and decomposed material
      • transmission via inhalation of spores
  • Epidemiology
    • risk factors
      • immunocompromised status
      • neutropenia
      • steroids or cytotoxic drugs
      • hematologic malignancy
      • chronic granulomatous disease
      • asthma
      • pre-existing lung disease
  • Pathogenesis
    • in patients with competent immune systems, immune system will clear any Aspergillus spores before it can germinate
    • invasive aspergillosis
      • in immunocompromised patients, spores will germinate and produce invasive hyphal structures
    • ABPA
      • local inflammatory reaction can cause an allergic response
  • Associated conditions
    • hepatocellular carcinoma from aflatoxins that Apsergillus produce
  • Prognosis
    • invasive aspergillosis
      • can have high mortality (> 60%) in severely immunocompromised patients
Presentation
  • Invasive aspergillosis
    • persistent fever
      • neutropenic patients may present with fever only
    • cough with hemoptysis
    • shortness of breath
    • chest pain
  • Aspergillomas
    • cough with hemoptysis
  • Allergic bronchopulmonary aspergillosis (ABPA)
    • new or worsening cough with hemoptysis
    • shortness of breath
    • brownish black mucus plugs in expectorate
    • asthma exacerbations (wheezing)
Imaging
  • Chest radiography
    • indication
      • all patients
    • findings
      • aspergilloma
        • round or ovoid mass, often mobile
  • Chest computed tomography (CT)
    • indication
      • all patients
    • findings
      • invasive aspergillosis
        • nodules with halo sign (rim of ground glass opacity)
        • cavitary lesions
      • aspergilloma
        • well-formed cavitary lesion, often mobile (changes as the patient changes position)
        • Monad sign
          • air surrounding soft tissue mass, indicating pre-existing cavity
      • ABPA
        • bronchiectasis
  • Bronchoscopy
    • indication
      • to obtain sample for culture or pathology
      • invasive aspergillosis
    • findings
      • tracheobronchial ulceration
      • nodules
      • pseudomembranes or plaques
Studies
  • Labs
    • detection of Aspergillus galactomannan antigen in serum, bronchoalveolar lavage fluid, or cerebrospinal fluid
    • eosinophilia and elevated IgE in those with ABPA
  • Biopsy of affected tissue
    • hyphae invasion into tissue
  • Culture of sterilely-obtained sample
    • positive culture
  • Making the diagnosis
    • invasive aspergillosis
      • definitive diagnosis of invasive aspergillosis requires either
        • pathologic examination with invasive hyphae in tissue
        • positive Aspergillus culture
    • ABPA
      • based on clinical findings and eosinophilia or elevated IgE
    • aspergilloma
      • abnormal sputum culture or positive culture or serology
      • aspergilloma seen on imaging
Differential
  • Pneumocystis pneumonia
    • distinguishing factors
      • hemoptysis is rare
      • often presents as progressive exertional shortness of breath
      • CT imaging shows bilateral and diffuse patchy ground-glass opacities
  • Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
    • distinguishing factor
      • often involves other organ systems, including skin, cardiac, gastrointestinal, and renal
Treatment
  • Medical
    • steroids
      • indications
        • first-line
        • ABPA
    • voriconazole
      • indications
        • first-line
        • invasive aspergillosis
    • caspofungin
      • indications
        • contraindication to voriconazole
        • invasive aspergillosis
    • amphotericin B
      • indication
        • often used as adjuvant therapy with voriconazole
        • invasive apsergillosis
  • Operative
    • surgical resection
      • indication
        • aspergilloma
Complications
  • Disseminated infection
  • Vascular invasion

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(M3.ID.15.4) A 26-year-old man is undergoing a bone marrow transplantation for treatment of a non-Hodgkin lymphoma that has been refractory to several rounds of chemotherapy and radiation over the past 2 years. He has been undergoing a regimen of cyclophosphamide and total body irradiation for the past several weeks in anticipation of his future transplant. This morning, he reports developing a productive cough and is concerned because he noted some blood in his sputum this morning. The patient also reports pain with inspiration. His temperature is 101°F (38.3°C), blood pressure is 115/74 mmHg, pulse is 120/min, respirations are 19/min, and oxygen saturation is 98% on room air. A chest radiograph and CT are obtained and shown in Figures A and B respectively. Which of the following is the most likely diagnosis?

QID: 102583
FIGURES:
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Aspergillus fumigatus

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Mycoplasma pneumonia

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Pneumocystis jiroveci pneumonia

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Staphylococcus aureus

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Streptococcus pneumonia

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M 10 E

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