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Aspergillosis Clinical Presentation

  • Author: Eloise M Harman, MD; Chief Editor: Ryland P Byrd, Jr, MD  more...
 
Updated: Aug 15, 2016
 

History

The four most common manifestations of Aspergillus lung disease (ie, allergic bronchopulmonary aspergillosis [ABPA], aspergilloma, chronic necrotizing pulmonary aspergillosis [CNPA], and invasive aspergillosis) have quite different clinical manifestations.

Allergic bronchopulmonary aspergillosis

ABPA is a syndrome occurring in asthmatic persons and patients with cystic fibrosis (CF) that results from a hypersensitivity reaction to Aspergillus colonization of the tracheobronchial tree. This syndrome may cause fever and pulmonary infiltrates that are unresponsive to antibacterial therapy.

Patients often have a cough and produce mucous plugs, which may form bronchial casts. They may have hemoptysis. People with asthma who have ABPA may have poorly controlled disease and difficulty tapering off oral corticosteroids. ABPA may occur in conjunction with allergic fungal sinusitis, with symptoms including chronic sinusitis with purulent sinus drainage.

Aspergilloma

Aspergilloma may manifest as an asymptomatic radiographic abnormality in a patient with preexisting cavitary lung disease due to sarcoidosis, tuberculosis, or other necrotizing pulmonary processes. In patients with HIV disease, aspergilloma may occur in cystic areas resulting from prior Pneumocystis jiroveci pneumonia. Of patients with aspergilloma, 40-60% experience hemoptysis, which may be massive and life threatening. Less commonly, aspergilloma may cause cough and fever.

Chronic necrotizing pulmonary aspergillosis

CNPA manifests as a subacute pneumonia unresponsive to antibiotic therapy, which progresses and cavitates over weeks or months. Patients with CNPA have underlying disease, such as steroid-dependent chronic obstructive pulmonary disease (COPD) or alcoholism, with symptoms that may include fever, cough, night sweats, and weight loss. Usually, patients have received prolonged courses of antibiotic therapy and sometimes empiric antituberculous therapy without response prior to diagnosis via biopsy or culture.

Invasive aspergillosis

Invasive aspergillosis typically manifests as fever, cough, dyspnea, pleuritic chest pain, and sometimes hemoptysis in patients with prolonged neutropenia or immunosuppression.

Aspergillus infection after organ transplantation most often occurs in bone marrow recipients. However, invasive aspergillosis may be observed in patients who have received lung, heart, and other solid organ transplants. Of these solid organ transplants, lung transplant recipients are at significant risk. In bone marrow transplant recipients, invasive aspergillosis has a bimodal distribution, occurring early with prolonged neutropenia before engraftment and later in the context of high-dose corticosteroid therapy for graft versus host disease.

In patients with leukemia and lymphoma, aspergillosis may occur after chemotherapy-induced bone marrow suppression, with resultant prolonged neutropenia, manifesting with persistent fever and pulmonary infiltrates despite broad-spectrum antibiotic therapy. Radiographic and CT scan images may reveal characteristic patterns, including nodules, cavitary infiltrates, and focal infiltrates.

Invasive aspergillosis is being increasingly observed in patients with COPD on long-term corticosteroid therapy.[1, 2]

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Physical

Physical findings in patients with aspergillosis are nonspecific.

In ABPA, the patient may have fever. Wheezing may be noted upon auscultation of the chest. The patient may produce mucous plugs upon coughing.

In patients with aspergilloma, signs of the underlying lung disease may be noted, including clubbing in patients with CF. Hemoptysis is frequently present.

In CNPA and invasive aspergillosis, the patient is febrile and may have evidence of lung consolidation. Patients may have hemoptysis. Patients with invasive aspergillosis may be tachypneic and have rapidly progressive worsening hypoxemia.

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Causes

ABPA is found in people with asthma and/or CF who are allergic to Aspergillus. The thick mucus found in the airways of these patients may make clearing inhaled Aspergillus spores difficult. Additionally, evidence of genetic susceptibility has been reported. Patients who have certain HLA alleles, particularly HLA-DR2, have increased susceptibility to ABPA, whereas HLA-DQ2 appears to be protective.[16]

Risk factors involved in the development of CNPA include underlying pulmonary disease (including COPD, interstitial lung disease, and previous thoracic surgery) and altered immune status due to chronic corticosteroid therapy, alcoholism, collagen-vascular disease, or chronic granulomatous disease.

Aspergilloma typically develops in the context of preexisting cavitary disease. Aspergillomas may develop in patients with invasive aspergillosis or chronic necrotizing Aspergillus pneumonia.

Invasive aspergillosis occurs almost exclusively in patients who are immunocompromised. Neutropenia and corticosteroid therapy are major risk factors. In addition to patients who have undergone transplantation, patients profoundly neutropenic after receiving chemotherapy for hematologic malignancies or lymphoma, children with chronic granulomatous disease, and patients with late-stage HIV disease also are at risk.

Specific risk factors for invasive aspergillosis after bone marrow transplantation include prolonged neutropenia, graft versus host disease, high-dose corticosteroid therapy, disruption of normal mucosal barriers, mismatched or unrelated donor transplants, and the presence of central venous catheters.

Invasive Aspergillus infection in patients without malignancy or prior chemotherapy (who probably are nevertheless not immunocompetent) is most commonly seen in those with critical illness and COPD who are taking long-term corticosteroid therapy.[17]

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Complications

ABPA may cause atelectasis, asthma exacerbation, and steroid dependence. Recurrent ABPA episodes may result in widespread bronchiectasis and fibrosis.

Hemoptysis is a frequent complication of aspergilloma.

Invasive aspergillosis may result in respiratory failure and death. Massive hemoptysis may occur. Aspergillus may disseminate to other organs, including the central nervous system, kidneys, and heart, and result in multisystem organ failure.

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Contributor Information and Disclosures
Author

Eloise M Harman, MD Staff Physician and MICU Director, Pulmonary Division, Gainesville Veterans Affairs Medical Center

Eloise M Harman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American Medical Womens Association, American Thoracic Society, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Acknowledgements

Oleh Wasyl Hnatiuk, MD Program Director, National Capital Consortium, Pulmonary and Critical Care, Walter Reed Army Medical Center; Associate Professor, Department of Medicine, Uniformed Services University of Health Sciences

Oleh Wasyl Hnatiuk, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

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