Epidemiology

• Occurs in patients with severe underlying lung disease
• Most cases have had modest degrees of immunosuppression: diabetics or chronic low-dose steroids
• Predisposing Factors
  • Anti-TNF Therapy (see [[Anti-TNF Therapy]]): increased risk with infliximab

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Etiology

• xxx

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Physiology

• Locally invasive, slowly progressive Aspergillus infection

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Pathology

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Diagnosis

Sputum GS/Cult+Sens

• Cultures positive for Aspergillus

FOB

• BAL cultures positive for Aspergillus

CXR/Chest CT patterns:

• Upper lobe cavitary infiltrates (unilateral or bilateral): resembles TB
  • Mycetoma may be present in one of the cavities
  • May extend to adjacent pleura

Serum Galactomannan

• False-Positive
  • Cross-reactivity with other fungi
  • Gut translocation of galactomannan present in milk and cereals
  • Gut translocation of galactomannan with GVHD occurring after bone marrow transplant
  • Use of piperacillin/tazobactam (Zosyn) or amoxicillin/clavulanate (Augmentin)
• False-Negative
  • Presence of anti-aspergillus antibodies
  • Localized or encapsulated infections
  • Use of antifungal therapy

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Clinical

• Pneumonia-like illness:

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Treatment

• Voriconazole: effective
• Itraconazole: may be useful for mild-moderate cases or chronic suppression
  • IV itra is available (limit use to 2 wks to avoid cyclodextrin nephrtoxicity/avoid with CrCl <30 ml/min)
• Ampho B: slows tissue destruction, but potential for cure is uncertain

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References

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