Aspergillosis Clinical Presentation

Updated: Jan 10, 2019
  • Author: Eloise M Harman, MD; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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Presentation

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. [21] It has also been observed in heart transplant recipients. [7]

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 Examination

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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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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