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Aspergillosis

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Topic updated on 06/14/17 5:46pm

Snapshot
  • A 7-year-old male with a past medical history of chronic granulomatous disease presents with hemoptysis. Chest radiograph and CT scan showed bilateral infiltrates and consolidation of the right upper lobe. Broncho-alveolar lavage was carried out and culture revealed fungi with septate hyphae branching at acute angles. (Invasive aspergillosis)
  • A 40-year-old male presents with a two month history of fever, cough, and night sweats. He had been treated adequately for pulmonary tuberculosis about a year ago. He is AAFB negative. Chest radiograph reveals a cavitary lesion in the left upper lobe. CT scan further showed a mobile mass within the cavity with a cresentic rim. Fine needle aspiration cytology revealed fungal hyphae and inflammatory cells. (Aspergilloma)
  • A 50-year-old male presents with a five day history of productive cough with brownish plugs of sputum. Two days ago he developed chest pain. He denies cough, fever, and shortness of breath. He is a known asthmatic on inhaled bronchodilators and corticosteroids. Chest radiograph revealed irregular consolidation of  the right upper and midddle lobes. Serum IgE was 6622 IU/ml, serum eosinophils was 1100 cells/mm3 and allergen-specific IgE for Apergillus fumigatus was 4+. (Allergic bronchopulmonary aspergillosis)
Introduction
  • Diseases
    • inhalation of ubiquitous Apergillus spores causes 3 diseases
    • allergic bronchopulmonary aspergillosis
      • asthma-like allergic reaction in airways
        • proximal bronchiectasis
      • type I and type IV hypersensitivity reactions
      • mucus plugs form but do not penetrate tissue
    • aspergilloma
      • seen in TB patients (or other granulomatous disease)
      • "fungus ball" forms in pre-existing lung cavities
    • invasive aspergillosis
      • invasive infection of the lung
      • usually in immunocompromised 
      • pleuritic pain and hemoptysis
      • infiltrate seen on radiograph and CT
  • Toxins
    • Aspergillus spp. produces aflatoxin
      • causes liver damage and liver cancer
        • aflatoxin B1 causes G:C → T:A mutation in codon 249 of p53 
        • increased risk of hepatocellular carcinoma
Evaluation
  • Laboratory
    • monomorphic
    • septate hyphae branch at acute angles 
      • "ASpergillus is Acute and Septate"
    • fruiting bodies are rare
    • a recycler (found in compost piles)
    • catalase-positive
Differential
  • Invasive aspergillosis
    • mucormycosis
  • Allergic bronchopulmonary aspergillosis
    • differential diagnosis of pulmonary eosinophilia
  • Aspergilloma
    • differential diagnosis of a pulmonary nodule/mass
Treatment
  • Allergic bronchopulmonary aspergillosis 
    • systemic corticosteroids and oral itraconazole
  • Aspergilloma
    • surgery
  • Invasive aspergillosis
    • voriconazole, amphotericin B, or caspofungin
Prognosis, Prevention, and Complications
  • Prognosis
    • poorest with invasive aspergillosis
      • seen in immunocompromised patients
      • neutropenia and glucocorticoid use predispose to infection


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Qbank (1 Questions)

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(M3.ID.4) A 26-year-old male is undergoing a bone marrow transplantation for treatment of a non-Hodgkin lymphoma that has been refractory to several rounds of chemotherapy and radiation treatments over the past 2 years. He has been undergoing a conditioning regimen of cyclophosphamide and total body irradiation for the past several weeks in anticipation of his future transplant. This morning, he reports developing a productive cough overnight, and is concerned because he noted some blood in his sputum this morning. The patient also reports pain with inspiration. His vital signs are as follows: T 38.8, HR 88, BP 128/78, RR 14, O2Sat 98%. A chest radiograph and CT are obtained and shown in Figures A and B respectively. No cavitary or necrotic lesions are noted on imaging. Which of the following should be suspected as the cause of this patient's current symptoms? Topic Review Topic
FIGURES: A   B        

1. Clostridium difficile infection
2. Invasive aspergillosis
3. Shigellosis
4. Pulmonary nocardiosis
5. Lyme disease

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