Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management

Abstract

Chronic pulmonary aspergillosis (CPA) is an uncommon and problematic pulmonary disease, complicating many other respiratory disorders, thought to affect ∼240 000 people in Europe. The most common form of CPA is chronic cavitary pulmonary aspergillosis (CCPA), which untreated may progress to chronic fibrosing pulmonary aspergillosis. Less common manifestations include: Aspergillus nodule and single aspergilloma. All these entities are found in non-immunocompromised patients with prior or current lung disease. Subacute invasive pulmonary aspergillosis (formerly called chronic necrotising pulmonary aspergillosis) is a more rapidly progressive infection (<3 months) usually found in moderately immunocompromised patients, which should be managed as invasive aspergillosis. Few clinical guidelines have been previously proposed for either diagnosis or management of CPA. A group of experts convened to develop clinical, radiological and microbiological guidelines. The diagnosis of CPA requires a combination of characteristics: one or more cavities with or without a fungal ball present or nodules on thoracic imaging, direct evidence of Aspergillus infection (microscopy or culture from biopsy) or an immunological response to Aspergillus spp. and exclusion of alternative diagnoses, all present for at least 3 months. Aspergillus antibody (precipitins) is elevated in over 90% of patients. Surgical excision of simple aspergilloma is recommended, if technically possible, and preferably via video-assisted thoracic surgery technique. Long-term oral antifungal therapy is recommended for CCPA to improve overall health status and respiratory symptoms, arrest haemoptysis and prevent progression. Careful monitoring of azole serum concentrations, drug interactions and possible toxicities is recommended. Haemoptysis may be controlled with tranexamic acid and bronchial artery embolisation, rarely surgical resection, and may be a sign of therapeutic failure and/or antifungal resistance. Patients with single Aspergillus nodules only need antifungal therapy if not fully resected, but if multiple they may benefit from antifungal treatment, and require careful follow-up. @ERSpublications ERS and ESCMID guideline for the management of chronic pulmonary aspergillosis released

Microbiological criteria in non-tuberculous mycobacteria pulmonary disease: a tool for diagnosis and epidemiology

“…1 Patients should have a combination of clinical, radiological and microbiological characteristics, together with the exclusion of alternative diagnoses. This approach, similar to the one recently proposed for the diagnosis and management of chronic pulmonary aspergillosis 7 , a disease that can follow or occur contemporaneously with NTM-PD, further emphasizes the complexity of the disease.…”

Intensive care medicine research agenda on invasive fungal infection in critically ill patients

“…Long-term oral antifungal therapy is recommended, whilst surgical excision of simple aspergilloma is suggested if technically possible. Hemoptysis may be controlled with tranexamic acid and bronchial artery embolization [67].…”

Perfil Clínico e Epidemiológico de Pacientes com Suspeita de Aspergilose Pulmonar em Hospital do Estado Rio Grande do Sul, Brasil

“…3,4 Desta forma, os pacientes de maior risco à infecção e à Aspergilose Pulmonar Invasiva (API), são indivíduos imunocomprometidos, nos quais o fungo pode causar uma variedade de sintomas, variando desde asma (ligeira e transitória) à doença pulmonar disseminada fatal. 5 A API é uma infecção grave caracterizada pela proliferação do micélio do fungo no parênquima pulmonar, associada normalmente com destruição tecidual do hospedeiro. 5 A infecção, entretanto, pode permanecer latente e, posteriormente, produzir choque séptico.…”

“…5 A API é uma infecção grave caracterizada pela proliferação do micélio do fungo no parênquima pulmonar, associada normalmente com destruição tecidual do hospedeiro. 5 A infecção, entretanto, pode permanecer latente e, posteriormente, produzir choque séptico. Os principais fatores de predisposição à doença invasiva são a neutropenia prolongada (contagem de leucócitos < 500 cél/mL, persistente por mais de 10 dias) associada principalmente a tratamentos quimioterápicos, transplante de medula óssea e/ou órgãos e neoplasias hematológicas.…”

“…A baixa sensibilidade de testes micológicos clássicos e o longo período de cultivo de fungos filamentosos em hemoculturas dificultam o reconhecimento precoce da infecção. 5,10,11 É descrito que muitos casos de aspergilose não são detectados antes do óbito do paciente. Somando a isso, a frequência de necropsias pulmonares no Brasil é baixa e, consequentemente, conclusões sobre a incidência da API e da condição epidemiológica não são fidedignos.…”