Medical Care

Aspergillosis treatment is based on the disease manifestation, which includes invasive disease in an immunocompromised host or allergic disease that includes allergic bronchopulmonary aspergillosis (ABPA) and colonizing syndromes (eg, aspergilloma, otomycosis) in an immunocompetent host.

When invasive aspergillosis (IA) is strongly suspected in an immunocompromised patient, empiric treatment with antifungal medications is the consensus therapy. Suspicion may be based on the clinical course of the illness, isolation of the fungus from the pulmonary and/or nasopharyngeal secretions, and failure to respond to initial antibacterial treatment. If a patient with profound neutropenia does not respond to broad spectrum antibiotics within 5-7 days, empiric treatment for invasive aspergillosis with antifungals is indicated.
Voriconazole has now become the drug of choice for invasive aspergillosis. This is due to the increased efficacy and significantly less toxicity compared to amphotericin B.
Caspofungin is a newer antifungal agent that is effective against invasive aspergillosis but more pediatric studies are needed prior to its widespread use. Currently caspofungin has been approved for use as salvage therapy for invasive aspergillosis that does not respond to existing antifungals.
- Treatment duration has not been well defined and is based on the clinical response and the tolerance to the drug. Continue therapy 4-12 weeks or longer.
- Itraconazole is used as prophylaxis in some cancer centers for immunocompromised patients.
ABPA exacerbations are treated with corticosteroids.^[15]
- The desired goal is to reduce serum immunoglobulin E (IgE) levels to a range consistent with levels obtained from patients with asthma (without ABPA) living in the same geographic area. Reinstitution of corticosteroid therapy may be required if the serum IgE levels rise to twice this level or higher.^[16]
- Immediately obtain IgE levels after corticosteroid therapy.
For asthma exacerbation, as indicated, administer other agents, such as beta-adrenergic agonists, high-dosage inhaled corticosteroids, and, possibly, nedocromil or theophylline.
Administer prednisone as a single morning dose for 2 weeks and then convert to an alternate-day dosage for 3 months.
Systemic antifungal therapy is not indicated for ABPA.

Surgical Care

See the list below:

Invasive aspergillosis requires surgical care in the following situations:
- In invasive pulmonary aspergillosis, resection of the fungal lesion is indicated when the lesion in localized, and or if disease is likely to cause perforation of the pulmonary artery with consequent hemoptysis.
- In immunocompromised patients, resection and surgical reduction of the Aspergillus mass is indicated before myeloablative procedures.
- In patients with osteomyelitis, surgical intervention, including thorough debridement, may help chronic invasive sinusitis and cutaneous lesions.
Surgical care is recommended in patients with aspergilloma only when severe hemoptysis occurs.
- Resection is the mainstay therapy for patients with adequately functioning lungs, although bronchial artery embolization may be considered for patients who are not candidates for resectional surgery.
- Systemic antifungal therapy is not indicated in patients with nonallergic colonization.

Guidelines

Tragiannidis A, Roilides E, Walsh TJ, Groll AH. Invasive Aspergillosis in Children With Acquired Immunodeficiencies. Clin Infect Dis. 2011 Nov 10. [QxMD MEDLINE Link].
Greenberger PA, Patterson R. Diagnosis and management of allergic bronchopulmonary aspergillosis. Ann Allergy. 1986 Jun. 56(6):444-8. [QxMD MEDLINE Link].
Buchheidt D, Reinwald M, Spiess B, Boch T, Hofmann WK, Groll AH, et al. Biomarker-based diagnostic work-up of invasive pulmonary aspergillosis in immunocompromised paediatric patients--is Aspergillus PCR appropriate?. Mycoses. 2016 Feb. 59 (2):67-74. [QxMD MEDLINE Link].
Fisher BT, Zaoutis TE, Park JR, Bleakley M, Englund JA, Kane C, et al. Galactomannan Antigen Testing for Diagnosis of Invasive Aspergillosis in Pediatric Hematology Patients. J Pediatric Infect Dis Soc. 2012 Jun. 1(2):103-111. [QxMD MEDLINE Link]. [Full Text].
Lehrnbecher T, Hassler A, Groll AH, Bochennek K. Diagnostic Approaches for Invasive Aspergillosis-Specific Considerations in the Pediatric Population. Front Microbiol. 2018. 9:518. [QxMD MEDLINE Link]. [Full Text].
Tong T, Shen J, Xu Y. Serum galactomannan for diagnosing invasive aspergillosis in pediatric patients: A meta-analysis. Microb Pathog. 2018 Mar 31. 118:347-356. [QxMD MEDLINE Link].
Pickering JW, Sant HW, Bowles CA, Roberts WL, Woods GL. Evaluation of a (1->3)-beta-D-glucan assay for diagnosis of invasive fungal infections. J Clin Microbiol. 2005 Dec. 43(12):5957-62. [QxMD MEDLINE Link]. [Full Text].
Desmet S, Van Wijngaerden E, Maertens J, et al. Serum (1-3)-beta-D-glucan as a tool for diagnosis of Pneumocystis jirovecii pneumonia in patients with human immunodeficiency virus infection or hematological malignancy. J Clin Microbiol. 2009 Dec. 47(12):3871-4. [QxMD MEDLINE Link]. [Full Text].
Aquino VR, Goldani LZ, Pasqualotto AC. Update on the contribution of galactomannan for the diagnosis of invasive aspergillosis. Mycopathologia. 2007 Apr. 163(4):191-202. [QxMD MEDLINE Link].
Pfeiffer CD, Fine JP, Safdar N. Diagnosis of invasive aspergillosis using a galactomannan assay: a meta-analysis. Clin Infect Dis. 2006 May 15. 42(10):1417-727. [QxMD MEDLINE Link].
Francesconi A, Kasai M, Petraitiene R, et al. Characterization and comparison of galactomannan enzyme immunoassay and quantitative real-time PCR assay for detection of Aspergillus fumigatus in bronchoalveolar lavage fluid from experimental invasive pulmonary aspergillosis. J Clin Microbiol. 2006 Jul. 44(7):2475-80. [QxMD MEDLINE Link].
Choi SH, Kang ES, Eo H, Yoo SY, Kim JH, Yoo KH, et al. Aspergillus galactomannan antigen assay and invasive aspergillosis in pediatric cancer patients and hematopoietic stem cell transplant recipients. Pediatr Blood Cancer. 2013 Feb. 60(2):316-22. [QxMD MEDLINE Link].
Koo S, Thomas HR, Daniels SD, Lynch RC, Fortier SM, Shea MM, et al. A breath fungal secondary metabolite signature to diagnose invasive aspergillosis. Clin Infect Dis. 2014 Dec 15. 59 (12):1733-40. [QxMD MEDLINE Link].
Skwarecki B. Breath Test May Diagnose Fungal Pneumonia. Medscape Medical News. Available at http://www.medscape.com/viewarticle/834035. October 29, 2014; Accessed: December 29, 2015.
de Benedictis FM, Bush A. Corticosteroids in Respiratory Diseases in Children. Am J Respir Crit Care Med. 2011 Sep 15. [QxMD MEDLINE Link].
Jat KR, Walia DK, Khairwa A. Anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev. 2013 Sep 17. 9:CD010288. [QxMD MEDLINE Link].
Patterson TF, Thompson GR 3rd, Denning DW, Fishman JA, Hadley S, Herbrecht R, et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Aug 15. 63 (4):e1-e60. [QxMD MEDLINE Link].
Parry NM. New Guidelines for the Management of Aspergillosi. Medscape Medical News. Available at http://www.medscape.com/viewarticle/865689. July 05, 2016; Accessed: August 16, 2016.
Kamalaporn H, Leung K, Nagel M, Kittanakom S, Calvieri B, Reithmeier RA, et al. Aerosolized liposomal amphotericin B: A potential prophylaxis of invasive pulmonary aspergillosis in immunocompromised patients. Pediatr Pulmonol. 2013 Jul 10. [QxMD MEDLINE Link].
Abbasi S, Shenep JL, Hughes WT, Flynn PM. Aspergillosis in children with cancer: A 34-year experience. Clin Infect Dis. 1999 Nov. 29(5):1210-9. [QxMD MEDLINE Link].
Blum MD, Weidermann BL. Aspergillus infections. Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. 5th ed. W B Saunders and Co; 2004. Vol 2: 2288-96.
Denning DW. Invasive aspergillosis. Clin Infect Dis. 1998 Apr. 26(4):781-803; quiz 804-5. [QxMD MEDLINE Link].
Dismukes WE. Antifungal therapy: lessons learned over the past 27 years. Clin Infect Dis. 2006 May 1. 42(9):1289-96. [QxMD MEDLINE Link].
Hetherington S. Etiologic agents of infectious disease. Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. 1st ed. Churchill Livingstone; 1997. 1326-32.
Kuhlman JE, Fishman EK, Burch PA, et al. Invasive pulmonary aspergillosis in acute leukemia. The contribution of CT to early diagnosis and aggressive management. Chest. 1987 Jul. 92(1):95-9. [QxMD MEDLINE Link].
Latge JP. Aspergillus fumigatus and aspergillosis. Clin Microbiol Rev. 1999 Apr. 12(2):310-50. [QxMD MEDLINE Link].
McWhinney PH, Kibbler CC, Hamon MD, et al. Progress in the diagnosis and management of aspergillosis in bone marrow transplantation: 13 years' experience. Clin Infect Dis. 1993 Sep. 17(3):397-404. [QxMD MEDLINE Link].
Patterson TF. Aspergillus species. Mandell GL, Benett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 6th ed. Churchill Livingstone; 2005. Vol 2: 2958-70.
Pickering LK. Aspergillosis. Pickering LK, ed. 2003 Red Book: Report of the Committee on Infectious Diseases. 26th ed. Elk Grove, IL: American Academy of Pediatrics; 2003. 208-10,725.
Segal BH, Walsh TJ. Current approaches to diagnosis and treatment of invasive aspergillosis. Am J Respir Crit Care Med. 2006 Apr 1. 173(7):707-17. [QxMD MEDLINE Link].
Steinbach WJ. Antifungal agents in children. Pediatr Clin North Am. 2005 Jun. 52(3):895-915, viii. [QxMD MEDLINE Link].
Steinbach WJ. Pediatric aspergillosis: disease and treatment differences in children. Pediatr Infect Dis J. 2005 Apr. 24(4):358-64. [QxMD MEDLINE Link].
Stevens DA, Kan VL, Judson MA, et al. Practice guidelines for diseases caused by Aspergillus. Infectious Diseases Society of America. Clin Infect Dis. 2000 Apr. 30(4):696-709. [QxMD MEDLINE Link].
Walmsley S, Devi S, King S, et al. Invasive Aspergillus infections in a pediatric hospital: a ten-year review. Pediatr Infect Dis J. 1993 Aug. 12(8):673-82. [QxMD MEDLINE Link].
Walsh TJ, Hiemenz JW, Seibel NL, et al. Amphotericin B lipid complex for invasive fungal infections: analysis of safety and efficacy in 556 cases. Clin Infect Dis. 1998 Jun. 26(6):1383-96. [QxMD MEDLINE Link].
White PL, Linton CJ, Perry MD, et al. The evolution and evaluation of a whole blood polymerase chain reaction assay for the detection of invasive aspergillosis in hematology patients in a routine clinical setting. Clin Infect Dis. 2006 Feb 15. 42(4):479-86. [QxMD MEDLINE Link].
Zaoutis TE, Heydon K, Chu JH, et al. Epidemiology, outcomes, and costs of invasive aspergillosis in immunocompromised children in the United States, 2000. Pediatrics. 2006 Apr. 117(4):e711-6. [QxMD MEDLINE Link].