Dr. Bala P DNB., IDCCM
Consultant Pulmonary and Critical Care Medicine
Shifa Hospitals, Tirunelveli.
Aspergillus species are ubiquitous in the environment. Aspergillosis is caused by inhalation of aspergillus spores. In normal hosts, Aspergillus rarely causes lung disease. Pulmonary aspergillosis covers a wide spectrum of clinical syndromes depending on the interaction between Aspergillus and the host.
15-year-old boy, K/c of Asthma and Allergic rhinitis came with c/o uncontrolled symptoms of cough, wheeze despite on adequate inhaler therapy. Workup for Allergic BronchoPulmonary Aspergillosis (ABPA) came positive-Started on tapering dose of oral steroid and Itraconazole. Clinically improved and Asthma symptoms became well controlled.
50-year-old male with h/o chronic ethanol abuse came with c/o acute onset left sided pleuritic chest pain of 1 week duration, cough and shortness of breath with hypoxia. CT Chest revealed left upper lobe consolidation. Bronchoscopic lavage grew Aspergillus Fumigatus and Galactomannan came positive-s/o invasive aspergillosis (IPA). He was treated with Voriconazole and clinically improved.
30-year-old male, with no prior comorbidities came with c/o chronic cough of 1 year duration with off/on high grade fever spikes and orange coloured sputum. Bronchoscopic lavage grew Aspergillus Fumigatus and Galactomannan came positive s/o invasive fungal disease. CT Chest revealed left upper lobe multiple cavities. A diagnosis of Chronic Cavitary Pulmonary Aspergillosis (CCPA) was made. He was treated with Voriconazole, clinically improved.
The above three cases, in different age groups presented in different clinical fashion, but all caused by same organism-Aspergillus Fumigatus.
A) Invasive Aspergillosis (IPA): Acute progressive infection that occurs in immunocompromised individuals and associated with high mortality. High risk groups include Neutropenia, Post-transplant recipients, Ethanol abuse, AIDS, Chronic steroid use. Diagnosis can be made by high index of clinical suspicion, BAL Galactomannan, Microbiological/Histopathological evidence of fungal invasion.
B) Chronic Pulmonary Aspergillosis (CPA): There are many chronic forms of aspergillosis. Progression of CPA is slow, commonly affecting people with chronic lung conditions including previous mycobacterial infections, COPD, Asthma, fibrocavitary disease. Diagnostic test of choice is Aspergillus fumigatus specific Ig G. Some common forms include Aspergilloma/Fungal Ball, Chronic Cavitary Pulmonary Aspergillosis (CCPA) and Chronic Necrotising Pulmonary Aspergillosis (CNPA).
C) Allergic Bronchopulmonary Aspergillosis (ABPA): Caused by hypersensitivity to Aspergillus Fumigatus, in patients with Asthma and Cystic Fibrosis. It has distinct clinical and radiographic manifestations such as refractory asthma, recurrent fleeting infiltrates with or without bronchiectasis. Treatment includes tapering dose of oral steroid and oral Itraconazole along with standard asthma management.
D) Aspergillus-associated Hypersensitivity Pneumonitis: Caused by exaggerated immune response to inhalation of large quantities of organic particles. Common causative agents include bird-derived proteins (Pigeons). Clinically presents either acutely as cough and shortness of breath or with chronic mild to moderate dyspnea and dry cough. Treatment includes oral steroid and avoiding further exposure to culprit agent.
Conclusion: The spectrum of disease caused by Aspergillus results from the interaction of Aspergillus, immune status and/or underlying lung disease of the host. One form of Aspergillosis may evolve into another depending of the degree of immunity of the host. A high level of suspicion may improve early diagnosis and treatment which are essential for improved outcomes.
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