Chronic cavitary pulmonary aspergillosis: Serial clinical and CT findings correlated with antifungal treatment and patient response

Abstract

Background: Chronic cavitary pulmonary aspergillosis (CCPA) is the most common form of chronic pulmonary aspergillosis.Objective: We hypothesise that by observing serial clinical and CT findings of CCPA patients with antifungal therapy, factors helping predict responses to antifungal therapy could be withdrawn.Methods: A total of 31 patients with CCPA who received antifungal therapy for greater than six months and who had serial CT studies were included. Clinical finding analyses were performed at initial and last follow-up CT acquisition dates. Clinical characteristics and CT features were compared between clinically improving or stable and deteriorating groups.Results: With antifungal therapy, neutrophil-to-lymphocyte ratio (2.66 vs. 5.12, p = .038) and serum albumin (4.40 vs. 3.85 g/dl, p = .013) and CRP (1.10 vs. 42.80 mg/L, p = .007) were different between two groups. With antifungal therapy, meaningful CT change, regardless of clinical response grouping, was decrease in cavity wall thickness (from 13.70 mm to 8.28 mm, p < .001). But baseline (p = .668) and follow-up (p = .278) cavity wall thickness was not different between two groups. In univariate analysis, initial maximum diameter of cavity (p = .028; HR [0.983], 95% CI [0.967-0.998]) and concurrent NTM infection (p = .030; HR [0.20], 95% CI [0.05-0.86]) were related factors for poor clinical response. Conclusions: With antifungal therapy, cavities demonstrate wall thinning. Of all clinical and radiological findings and their changes, initial large cavity size and concurrent presence of NTM infection are related factors to poor response to antifungal therapy.

Predictive factors for treatment response and mortality in chronic pulmonary aspergillosis

“…The association was strongest with enlarging cavity size. This finding is consistent with the observation by Nam et al 7 that cavity size was correlated with clinical outcomes. A larger cavity size may indicate progression of infection, as well as loss of underlying lung function, both contributing to subsequent deterioration and mortality.…”

“…This finding is consistent with the observation by Nam et al 7 F I G U R E 1 Kaplan-Meier curve of survival according to overall response (favourable response defined as: clinically better/stable and radiologically better/stable). predictor of mortality (Figure 2B); therefore, maintaining radiological stability may be a desirable outcome after a trial of antifungals, particularly in cases where deterioration was occurring before antifungals were started.…”

“…Godet et al 6 reported that clinical response was associated with loss of fungal ball and reduction in cavity wall and pleural thickness. In their cohort of CPA patients, Nam et al 7 found that while antifungal therapy resulted in decreased cavity wall thickness, this was not associated with clinical response, while initial large cavity size was associated with clinical deterioration. These studies used assessments of clinical response based in part on patient reported clinical symptoms, which may be affected by progression of underlying lung disease, for example COPD or sarcoidosis, independent from the progression or otherwise of CPA.…”

Chronic pulmonary aspergillosis: comprehensive insights into epidemiology, treatment, and unresolved challenges

“… 60 , 352 , 353 Risk factors for recurrence of CPA include involvement of more than one lung lobe, a large initial maximum cavity diameter, and concurrent infection with nontuberculous mycobacteria. 352 – 354 …”