Chest
Volume 146, Issue 5, November 2014, Pages 1358-1368
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Recent Advances in Chest Medicine
Diagnosis and Treatment of Pulmonary Aspergillosis Syndromes

https://doi.org/10.1378/chest.14-0917Get rights and content

Both inherited and acquired immunodeficiency and chronic pulmonary disease predispose to the development of a variety of pulmonary syndromes in response to Aspergillus, a fungus that is ubiquitous in the environment. These syndromes include invasive aspergillosis, which is now recognized to occur in patients with critical illness without neutropenia and in those with mild degrees of immunosuppression, including from corticosteroid use in the setting of COPD. Chronic pulmonary aspergillosis includes simple aspergilloma, which is occasionally complicated by life-threatening hemoptysis, and progressive destructive cavitary disease requiring antifungal therapy. Allergic bronchopulmonary aspergillosis occurs almost exclusively in patients with asthma or cystic fibrosis. Recent advances in each of these syndromes include a greater understanding of the underlying pathophysiology and hosts at risk; improved diagnostic algorithms; and the availability of more effective and well-tolerated therapies. Improvement in outcomes for Aspergillus pulmonary syndromes requires that physicians recognize the varied and sometimes subtle presentations, be aware of populations at risk of illness, and institute potentially life-saving therapies early in the disease course.

Section snippets

Invasive Aspergillosis: Epidemiology, Diagnostic Testing, and Treatment Updates

Invasive aspergillosis has been described classically in patients with neutropenia in the setting of hematologic malignancy but is seen increasingly in patients with even milder immune compromise from immunosuppression, chronic pulmonary or liver disease, or critical illness.7 As the portal of entry, the upper and lower respiratory tracts are most commonly infected, although dissemination to any organ may occur.Aspergillus tracheobronchitis and CNS infection are associated with especially poor

Chronic Pulmonary Aspergillosis

Chronic pulmonary aspergillosis refers to a spectrum of diseases, from simple aspergilloma to progressive cavitary aspergillosis (Table 1). Simple aspergillomas form in preexisting cavities, which sequester spores from clearance and the resulting fungus ball from immune responses (Fig 3). Positive precipitins or elevated serum IgG titers to Aspergillus are often observed.7, 33Except when hemoptysis occurs, the clinical course is typically benign with long-term radiographic stability. Patients

ABPA: Diagnostic and Treatment Options

ABPA is the result of immune-mediated damage to, and dysfunction of, the airways triggered by Aspergillus (Fig 5). Modifications to diagnostic criteria developed decades ago have been proposed in recent years (Table 4).64, 65Aspergillus-specific IgE levels may be more sensitive than skin testing for establishing sensitization. In a recent evaluation of diagnostic criteria,Aspergillus-specific IgE levels were increased in 100% of patients with ABPA.66 This was the most sensitive finding for

Other Syndromes Caused by Aspergillus Sensitization

Aspergillus sensitization can cause hypersensitivity pneumonitis or can complicate asthma. The features of hypersensitivity pneumonitis have been reviewed elsewhere.77 Severe asthma with fungal sensitization (SAFS) is an emerging disease concept. Although fungal sensitization can be associated with severe asthma, a direct role of sensitization in the disease process remains unclear. Unlike the syndromes described earlier,Aspergillus germination is not thought to be a feature of SAFS. SAFS is

Conclusions

Aspergillus is a ubiquitous organism that is encountered regularly in the environment. Although preexisting lung disease or immune dysfunction have long been recognized as prerequisites for the development of pulmonary disease in response to Aspergillus, recent studies demonstrate that even a modest degree of immunosuppression increases this risk, where the type of pulmonary response is often a function of host factors. Invasive pulmonary aspergillosis is encountered in patients with chronic

Acknowledgments

Financial/nonfinancial disclosures:The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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