- fungal disease caused by the mold Aspergillus, ranging from hypersensitivity to invasive infection.
- Important species include Aspergillus fumigatus, niger, flavus, calavtus
- transmission by inhalation
- high mortality
Spectrum from hypersensitivity reactions to angioinvasive disease
(1) allergic bronchopulmonary aspergillosis (ABPA) (can progress from asthma, to bronchiectasis and pulmonary fibrosis)
(2) aspergilloma (fungal ball in a pre-existing cavity)
(3) chronic necrotizing pneumonia (“semi-invasive”)
(4) invasive aspergillosis (airways and/or angioinvasive)
In the immunocompromised:
- haematogenous dissemination
- abscesses anywhere
- genetic predisposition
- underlying lung disease: asthma, CF, COPD, interstitial lung disease, previous thoracic surgery, Tb
- liver cirrhosis
- immunosuppression: steroids, collagen vascular disease, chronic granulomatous disease, neutropenia, organ transplantation, HIV
May occur in ‘non-immunocompromised’ critically ill patients
- Serum galactomannan: screening test of a major component in the cell wall of Aspergillus
- Sputum: Aspergillus radioallergosorbent assay test and culture, sliver staining
- IgG or IgE for Aspergillus
- peripheral eosinophilia
- CXR: fungal ball
- CT: nodules, cavities, alveolar infiltrates; ‘monod sign’ (air around an aspergilloma), ‘finger in glove’ (mucus impaction in ABPA),`halo sign’ (a pulmonary mass surrounded by a zone of lower attenuation with ground-glass opacification produced by adjacent haemorrhage); `air crescent sign’ (crescentic radiolucencies around a nodular area of consolidation)
- depends on clinical presentation
- supportive are and monitoring
- treat underlying causes and complications
- specific therapies
- respiratory isolation
- prophylactic anti-fungal treatment
- inhaled amphotericin B
- empiric treatment: voriconazole or amphotericin B
- neutropenia: G-CSF
Chronic necrotizing pulmonary aspergillosis
- voriconazole, or
- caspofungin, or
- amphotericin B
- surgical resection
- oral itraconazole (interacts with PPI)
- percutaneous instillation of amphotericin
- haemoptysis: embolization
Allergic bronchopulmonary aspergillosis (ABPA)
- oral corticosteroids
- oral itraconazole
References and Links
- Meersseman W, Lagrou K, Maertens J, Van Wijngaerden E. Invasive aspergillosis in the intensive care unit. Clin Infect Dis. 2007 Jul 15;45(2):205-16. PMID: 17578780.
- Sherif R, Segal BH. Pulmonary aspergillosis: clinical presentation, diagnostic tests, management and complications. Curr Opin Pulm Med. 2010 May;16(3):242-50. PMC3326383.
- Trof RJ, Beishuizen A, Debets-Ossenkopp YJ, Girbes AR, Groeneveld AB. Management of invasive pulmonary aspergillosis in non-neutropenic critically ill patients. Intensive Care Med. 2007 Oct;33(10):1694-703. PMC2039828.
FOAM and web resources
- Radiopaedia — Pulmonary aspergillosis (has additional links to the various types)
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.