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  • • Infection via inhalation of conidia into areas of lung with impaired mucociliary function (ie, tuberculous cavities)

    • 3 types of aspergillosis infections:

    • 1. Allergic bronchopulmonary aspergillosis

      2. Invasive aspergillosis

      3. Aspergilloma (fungus balls)

Allergic Bronchopulmonary Aspergillosis

  • • Occurs in patients with asthma or cystic fibrosis

    • Fungal growth leads to dilated airways filled with mucus and fungus

    • 5 stages of infection:

    • 1. Acute infection

      2. Corticosteroid-induced remission

      3. Asymptomatic worsening of laboratory and x-rays

      4. Onset of corticosteroid-dependent asthma

      5. End-stage fibrosis

Invasive Aspergillosis

  • • Found only in immunocompromised patients

    • Patients with leukemia: 50-70% of cases

    • Dissemination frequent

    • 3 types of pulmonary disease described

    • 1. Tracheobronchitis: Larger airways with mucosal ulceration, fungal plugs

      2. Necrotizing bronchopneumonia

      3. Hemorrhagic infarction: Occlusion of arteries with necrosis

Aspergilloma (Fungus Balls)

  • • Divided into 2 types:

    • 1. Simple, thin-walled cysts with ciliated epithelium surround by normal lung

      2. Complex cavities with abnormal surrounding lung tissue

    • Most often in upper lobes, multiple (22%), calcification and air-fluid levels rare

    • Associated with cavitary lung disease (TB, histoplasmosis, sarcoidosis, bronchiectasis, etc)

Epidemiology

  • • Pulmonary fungal infections are rising due to widespread use of broad-spectrum antibiotics, immunosuppressive drugs, and HIV infection

    • Occur anywhere in world, some with characteristic endemic areas

Aspergillosis

  • Aspergillus fumigatus (most common), Aspergillus niger, Aspergillus flavus, Aspergillus glaucus

    • Second most common opportunistic fungal infection after candidiasis

    • Third most common fungal infection requiring hospital care

Symptoms and Signs

Allergic Bronchopulmonary Aspergillosis

  • • Cough, fever, wheezing, dyspnea, pleuritic pain, hemoptysis

Invasive Aspergillosis

  • • Cough, dyspnea, wheezing, aspergilloma

    • Hemoptysis (50-80%), can be multiple recurrent episodes

Imaging Findings

Allergic Bronchopulmonary Aspergillosis

  • Chest film: Homogenous densities in "gloved finger," inverted "Y," or "cluster of grapes" pattern

Invasive Aspergillosis

  • Chest film: Patchy areas of atelectasis secondary to bronchial obstruction, cavitation common, "air crescents" of mycotic lung

Aspergilloma

  • Chest film: 3-6 cm round, mobile density with crescent of air

  • • Definitive diagnosis: Demonstration of hyphal tissue invasion or documentation of hyphae on silver stain in suspected aspergilloma

    • Diagnosis suggested: Culturing uniform septate hyphae with dichotomous branching at 45 degrees, detection of specific IgG or IgE antibodies

  • • Chest x-ray

    • Chest CT scan

    • Sputum culture

Allergic Bronchopulmonary Aspergillosis

  • • Medical therapy (corticosteroids)

Invasive Aspergillosis

  • • Amphotericin B (mortality still 90%)

Aspergillomas

  • • Surgery indicated for complications of aspergillous infections

    • Wide resection (lobectomy) required

    • In some high risk patients, cavernostomy + muscle flap ...

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