Aspergillus Disorders

Question 1

What is the mechanism of action of triazoles?

Answer 1

Inhibition of 14-alpha-sterol demethylase. Impairs aspergillus membrane integrity

Question 2

What are the first, second and 3rd line anti fungal therapies in simple ABPA/CPA?

Answer 2

1: Itraconazole 200mg BD
2: Voriconazole 200mg BD
3: Posaconazole 300mg OD

Question 3

What are the indications to treat an aspergilloma? (5)

Answer 3

1: Multiple episodes of minor haemoptysis
2: Episode of major haemoptysis
3: Significant systemic symptoms (fever, weight loss, lethargy, night sweats)
4: Radiological progression (indicating CPA)
5: Pending/current increased immunosuppression

Question 4

What are the treatments for acute ABPA exacerbations?

Answer 4

1: PO prednisolone- 0.5mg/kg (max 40mg) for up to 2 weeks then taper to maintenance/zero over 2-8 weeks
2: PO anti fungal if high risk with steroids or poor response- PO Itraconazole 200mg BD first line
3: Try to avoid co-therapy as can lead to adrenal suppression

Question 5

What are the diagnostic criteria for ABPA?

Answer 5

1: Total IgE >500 IU/ml (often >1000)
2: Positive IgE aspergillus >0.35 or positive skin prick test
3: Presence of obstructive airways disease +/- reversibility
Radiology: May have fleeting opacities/consolidation, finger in glove opacities (mucocoeles). May have proximal bronchiectasis on CT, centrilobular nodules or mosaic attenuation

Question 6

What is Step 2 of Chronic ABPA treatment?

Answer 6

Increase inhaled therapy to high dose ICS and LABA. Consider adding LAMA or oral theophylline

Question 7

What is Step 1 of Chronic ABPA treatment? (Lifestyle and Pharma)

Answer 7

Smoking cessation, mucous clearance, environmental avoidance
Inhaled corticosteroid and PRN SABA

Question 8

What are Steps 3A, 3B and 3C of Chronic ABPA management?

Answer 8

3A: Oral prednisolone 10mg OD for 3 months then 5mg OD for 3 months. Aim to wean at 6 months
3B: Oral anti fungal treatment. PO itraconazole 200mg BD first line
3C: Specialist asthma centre referral for biologic therapy

Question 9

What are the diagnostic criteria for Chronic Pulmonary Aspergillosis

Answer 9

Duration of >3 months with focal progression (usually have chronic lung disease/immunosuppression)
Positive culture, galactomannan or PCR of aspergillus from resp samples OR positive histology
Often serum IgG to aspergillus raised
Radiological changes in keeping with CPA

Question 10

What are the radiological changes associated with Subacute Invasive Aspergillosis (SAIA) ?

Answer 10

Enlarging aspergillus nodules +/- surrounding GGO (Halo sign)- indicating surrounding haemorrhage +/- cavitation

Question 11

What is the mortality of surgical resection of aspergilloma and should anti fungal treatment be given?

Answer 11

Surgical mortality up to 4%
Should have preoperative anti fungal treatment for at least 4 weeks

Question 12

What is the risk of developing an aspergilloma in a lung cavity of 2cm?

Answer 12

15-20%