Soubani AO, Chandrasekar PH. The clinical spectrum of pulmonary aspergillosis. Chest. 2002;121(6):1988-99.
Take home points:
1. There are four types of pulmonary aspergillosis: aspergilloma, chronic necrotizing aspergillosis, invasive pulmonary
aspergillosis, and allergic bronchopulmonary aspergillosis (ABPA)
2. Think of invasive pulmonary aspergillosis in the neutropenic, BMT, or solid organ transplant patient who develops
hemoptysis, pleuritic chest pain, and has a CT chest with multiple nodules, pulmonary infarction, and pleural-based
Aspergilloma (a.k.a. “fungus ball”):
• Develops in pre-existing lung cavity (most commonly from TB).
• Can be asymptomatic; if symptomatic, most common presentation is hemoptysis.
• Look for cavity with “fungus ball” on chest CT; fungus ball is gravity dependent.
• Antifungals not necessary if asymptomatic; if symptomatic, difficult to treat given walled off cavity.
Chronic necrotizing aspergillosis (semi-invasive aspergillosis):
• Develops in moderately immunocompromised hosts (e.g. COPD/chronic lung disease on steroids).
• Progresses over months to years. CXR shows infiltrate in upper lobes or superior segments of lower lobes.
• Treat with IV ampho or itraconazole (or newer azole agents).
Invasive pulmonary aspergillosis:
• Develops in BMT (32%), hematologic malignancy (29%), solid organ transplantion (9%), and HIV (8%).
• Presents with pleuritic CP and hemoptysis (from pulmonary infarction due to angioinvasive quality of aspergillus).
• On CT look for multiple nodules, the “halo sign” (hemorrhage surrounding a nodule), the “crescent sign” (necrosis
around a nodule), pleural-based infiltrates.
• Treatment difficult, high mortality. Use ampho or voriconazole and reverse underlying immunosuppression if possible.
Allergic bronchopulmonary aspergillosis (ABPA):
• Develops most commonly in asthmatics or CF due to hypersensitivity reaction to aspergillus antigens.
• Usually presents with refra