CASE REPORT

CASE SUMMARY

 Mrs.Rajamani,55 year female

 Hemoptysis for 5 years,increased last 6

months
 Massive hemoptysis two episodes last week
 H/o productive cough,intermittent fever
 No H/o epistaxis,chest pain,wheezing or

rhinitis
 H/o pulmonary tuberculosis 15 yrs back
Emaciated,anaemic
Vitals stable.no dyspnoea
Trachea to the right.
B/l supra and infraclavicular hollowing .
All areas resonant.
Bronchovesicular breath sounds heard in
right infraclavicular region.
All other systems normal.
INVESTIGATIONS
 BLOOD ROUTINE –WNL
 ESR-26mm/hr
 SPUTUM AFB-NEGATIVE
 SPUTUM CULTURE AND SENSITIVITY-NO GROWTH
 BT-1 mt
 CT-4 mt 5 sec
CHEST XRAY PA VIEW
CHEST XRAY RIGHT LATERAL DECUBITUS
CT SCAN THORAX
ASPERGILLOSIS
Aspergillus fumigatus is the most common cause of
aspergillosis. A. flavus, A. niger, A. nidulans, A. terreus, and
several other species can also cause disease.
Pulmonary aspergillosis
 Aspergilloma
◦ Balls of hyphae within cysts or cavities
 Allergic bronchopulmonary aspergillosis (ABPA)

◦ Hypersensitivity reaction to mycelium

◦ Severe asthma with fungal sensitisation(SAFS)
 Chronic necrotizing (semi-invasive) aspergillosis

◦ Cavitary illness with preexisting chronic lung

disease
 Angioinvasive (invasive) aspergillosis

Occurs in immunocompromised hosts

 Sinus aspergillosis
 Cutaneous aspergillosis
 Otomycosis: growth of aspergillus on cerumen and

detritus within the external auditory canal

 Keratitis: initiated by trauma to the cornea
 Endophthalmitis: introduction of aspergillus into the

globe by trauma or surgery

 Infection of intracardiac or intravascular prostheses

(rare)
RISK FACTORS

Immunosuppression (angioinvasive infection)

Structural lung disease, particularly cavitation
(aspergilloma, chronic invasive infection)
 Tuberculosis
 Sarcoidosis
 Bronchiectasis
 Histoplasmosis
 Asthma
 Cystic fibrosis
DIAGNOSIS
 Aspergillus hyphae can be identified presumptively
by histology, but culture is required for confirmation
and for identification of the species.
 Sputum/bronchoalveolar lavage (BAL) fluid
 Serum antibodies/antigens

◦ Aspergillus precipitins
◦ Specific serum IgE antibody to Aspergillus antigens
 Serum IgE level often >1000 ng/mL
◦ Galactomannan antigen
 Blood culture

◦ Rarely positive, even in patients with infected

cardiac valves (native or prosthetic)
D/D OF air crescent sign
 Other angioinvasive fungal infections
 Bland thromboembolism.
 A cavitating neoplasm,
 Tuberculosis,
 Nocardiosis
 Bacterial lung abscess
Diagnostic Procedures

 Biopsy is usually required for the diagnosis of

invasive aspergillosis of the lung, nose,
paranasal sinus, bronchi, or sites of
dissemination.
 Bronchoscopy with BAL and transbronchial

biopsies can be done.

 Alternative: CT-guided transthoracic biopsy
Treatment Approach

ASPERGILLOMA
Surgical resection (especially with severe
hemoptysis)
ABPA
An oral glucocorticoid is the treatment of
choice.
CHRONIC PULMONARY
antifungals-itraconazole
INVASIVE ASPERGILLOSIS
Early antifungal therapy is imperative.
ANTIFUNGALS
 VORICANOZOLE oral-200 mg bd,iv dose-6mg/kg bd
followd by 4mg/kg bd.
 ITRACONAZOLE - 200mg bd
 POSACONAZOLE- 400 mg bd
 CASPOFUNGIN-70mg followed by 50 mg/day
 MICAFUNGIN-150mg/day
 AMPHOTERICIN B deoxycholate 1mg/kg/day
 Lipid formulations 3mg to 5mg/kg/day
ABPA
 Preferred treatment: short courses of glucocorticoids
 Alternative treatment: itraconazole prophylaxis

◦ Oral itraconazole (200 mg bid)

 Patients may require less glucocorticoid therapy
and have fewer exacerbations.
◦ Itraconazole has been used with glucocorticoids to
treat exacerbations.
Invasive aspergillosis

 Preferred treatment: voriconazole

 Second-line treatment: liposomal or

conventional AmB
 Alternative treatment:

◦ Itraconazole
◦ Posaconazole
◦ IV caspofungin
THANK
YOU