Chest
Recent Advances in Chest MedicineDiagnosis and Treatment of Pulmonary Aspergillosis Syndromes
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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