Aspergillus Lung Disease

Question 1

What is Aspergillus Lung Disease?

Answer 1

Lung disease due to aspergillus fungal infection. Most commonly Aspergillus Fumigatus.

Question 2

What are the three main types of aspergillus lung disease?

Answer 2

ASPERGILLOMA
Growth of Aspergillus fumigatus mycetoma ball in a pre-existing lung gacivty (e.g. post-TB)

ALLERGIC BRONCHO-PULMONARY ASPERGILLOSIS (ABPA)
Coloniation of airways by Aspergillus leads to IgE and IgG-mediated responses, eosinophilic inflammation causing airway damage and central bronchiectasis

INVASIVE ASPERGILLOSUS
Invasion into lung tissue and fungal dissemination – secondary to immunosuppression.

Question 3

How might an aspergilloma present?

Answer 3

Asymptomatic/haemoptysis + tracheal deviation

Question 4

How would you investigate an aspergilloma?

Answer 4

CXR: Round opacity with surrounding crescent of air, in upper lobes. CT/MRI may be needed if CXR doesn’t delineate the cavities.

Culture may be negative

Question 5

How would you manage an aspergilloma?

Answer 5

May need surgical resection if large/recurrent haemoptysis, + itraconazole for residual disease

Question 6

What are some complications of an aspergilloma?

Answer 6

secondary bacterial infection, massive haemoptysis/haemorrhage

Question 7

How might ABPA present?

Answer 7

asthma that is difficult to control; recurrent pneumonia with wheeze; cough; fever + dullness in affected lung, reduced breath sounds

Question 8

How would you investigate ABPA?

Answer 8

Immediate skin test for reactivity to Aspergillus antigens

Bloods: ↑ serum total IgE ;↑ IgE and IgG specific to Aspergillus

CXR: transient patchy shadows, collapse, “gloved fingers” (distended bronchi plugged with mucus)

CT: lung infiltrates, central bronchiectasis

PFTs: reversible airflow limitation

Question 9

Which Ig’s would be elevated in ABPA?

Answer 9

IgE and IgG

Question 10

What feature might you see on a CXR in ABPA?

Answer 10

‘Gloved finger’ due to mucus plugging of dilated bronchi

Question 11

How would you manage ABPA?

Answer 11

Steroids + itraconazole for 3-6 months

May assist asthma using bronchodilators + inhaled steroids

Question 12

How would you monitor whether ABPA was getting better?

Answer 12

Monitor disease via total serum IgE and PFTs

Question 13

What are some possible complications of ABPA?

Answer 13

worsening of asthma, bronchiectasis, lobar collapse, lung fibrosis, respiratory failure

Question 14

How might you expect invasive aspergillosis to present?

Answer 14

dyspnoea, sepsis, cyanosis

Question 15

How would you investigate invasive aspergillosis?

Answer 15

• Histological exam – to detect Aspergillus – via bronchioalveolar lavage/sputum/test positive for galactomannan, beta-D-glucan assay
• Chest CT – nodules with ‘ground glass’ appearance, indicating haemorrhage into surrounding tissue

Question 16

What does the ‘ground glass’ appearance on a CT indicate?

Answer 16

Haemorrhage into surrounding tissue

Question 17

How would you manage invasive aspergillosis?

Answer 17

o ↓ immunosuppression if possible
o Voriconazole (IV, then oral)
o Can add baspofungin if pt is not responding

Question 18

For how long would you continue Tx in invasive aspergillosis?

Answer 18

Continue ALL anti-fungal therapy until ALL signs of disease are gone for 2 weeks

Question 19

What are some possible complications of invasive aspergillosis?

Answer 19

Septic shock, respiratory failure