• Aspergillus pulmonary disease takes three main forms: invasive aspergillosis, aspergilloma, and
ABPA (allergic bronchopulmonary aspergillosis). The first two are much more severe and present
very differently from ABPA.
Invasive aspergillosis usually occurs in patients who are already immunocompromised; it is diagnosed
by biopsy stains plus biopsy culture, but persistently positive sputum cultures in the appropriate patient
population have a high PPV
• Aspergillomas are fungus balls in cavities that are usually pre-existing; treatment is surgical resection
• ABPA most commonly presents like treatment-resistant asthma with brown sputum and fleeting
pulmonary infiltrates as well as eosinophilia.
From most to least severe…
1. Invasive aspergillosis: Usually occurs in patients who are somehow immunocompromised. Aspergillus
is angioinvasive, so it may result in pleuropulmonary hemorrhage or more commonly infarction.
• Usually presents with persistent fevers; may have chest pain, cough and hemoptysis
• CXR may be normal in up to 10% of cases, or may show wedge-shaped pleural-based densities
late in the disease; chest CT will pick up more subtle infarctions early on and is rarely normal
• Diagnosis is made by evidence of the fungus on special stains of biopsied lung PLUS positive
cultures for Aspergillus from the biopsy specimen. Positive sputum cultures, while not diagnostic,
should be taken seriously in immunocompromised patients, as they have a positive predictive
value of 80-90% in that population. BAL washings are similarly useful but not diagnostic.
• Treatment usually begins with IV amphotericin and then a transition to po itraconazole later in
the course. Two studies have been performed with po itraconazole alone that showed efficacy
comparable to IV ampho, but standard practice still seems to be to begin with IV ampho.
2. Aspergilloma: Usually occurs in patients with underlying lung disease.
• Fungus ball (a.k.a. “mycetoma”)