Aspergillus

Question 1

what are the five ways aspergillus fungi can affect the lung?

Answer 1

1. asthma
2. allergic bronchopulmonary aspergillosis
3. aspergilloma
4. invasive aspergillosis
5. extrinsic allergic alveolitis

Question 2

which other fungals can cause pneumonia in the immunosuppressed?

Answer 2

candida and cryptococcus

Question 3

how does A cause asthma

Answer 3

type 1 hypersensitivity reactions to fungal spores

Question 4

how does A cause allergic bronchopulmonary aspergillosis (ABA) ?

Answer 4

Results from type I and III
hypersensitivity reactions to Aspergillus fumigatus. Af ects 1–% of asthmatics,
2–25% of CF patients.2

Question 5

what happens to the lung in ABA

Answer 5

Early on, the allergic response causes bronchoconstriction,

but as the inflammation persists, permanent damage occurs, causing bronchiectasis

Question 6

what are the symptoms of ABA?

Answer 6

wheeze, cough, sputum (plugs of mucus containing fungal hyphae)

get dyspnoea and ‘recurrent pneumonia

Question 7

how is ABA investigated?

Answer 7

CXR, Aspergillus in sputum; positive Aspergillus skin test and/or Aspergillus-specifi c IgE RAST (radioallergosorbent test); positive serum precipitins; eosinophilia; raised serum IgE.

Question 8

how is ABA treated?

Answer 8

• prednisolone 30–40mg/24h PO for acute attacks; maintenance
  dose 5–10mg/d.
• Sometimes itraconazole is used in combination with corticosteroids.
• Bronchodilators for asthma.
• Sometimes bronchoscopic aspiration of
  mucous plugs is needed.

Question 9

what would a CXR of ABA show?

Answer 9

transient segmental collapse or consolidation, bronchiectasis

Question 10

what is aspergilloma?

Answer 10

a fungus ball within a pre-existing cavity (often caused by TB or sarcoidosis)

Question 11

how does aspergilloma present ?

Answer 11

It is usually asymptomatic but may cause cough,

haemoptysis (may be torrential), lethargy ± weight loss

Question 12

what investigations should be done for aspergilloma?

Answer 12

CXR: (round opacity within a cavity, usually apical); sputum culture; strongly positive
serum precipitins; Aspergillus skin test (30% +ve)

Question 13

what is the treatment for aspergilloma?

Answer 13

only if symptomatic

consider surgical excision for solitary symptomatic lesions or severe haemoptysis.

Oral itraconazole and other antifungals have been tried with limited success.

Local instillation of amphotericin paste under CT guidance yields
partial success in carefully selected patients, eg in massive haemoptysis.

Question 14

who is at risk of invasive aspergillosis ?

Answer 14

immunocompromise, eg HIV, leukaemia, burns, Wegener’s

, and SLE, or after broad-spectrum antibiotic therapy

Question 15

what investigations should be done for aspergillosis ?

Answer 15

sputum culture; BAL; biopsy; serum precipitins; CXR (consolidation, abscess).

Early chest CT and serial serum measurements of galactomannan (an Aspergillus antigen) may be helpful.

Diagnosis may only be made at lung biopsy or autopsy.

Question 16

what is the treatment for aspergillosis?

Answer 16

voriconazole is superior to IV amphotericin. 24 Alternatives:
IV miconazole or ketoconazole (less ef ective). Prognosis: 30% mortality

Question 17

how does EAA develop?

Answer 17

may be caused by sensitivity to Aspergillus
clav atus (‘malt worker’s lung’). Clinical features and treatment are as for other
causes of EAA

Question 18

how is a diagnosis of EAA made?

Answer 18

Diagnosis is based on a history of exposure and presence

of serum precipitins to A. clavatus.

Question 19

what may occur if the EAA is untreated?

Answer 19

fibrosis