History

Fact Explanation
Cough with mucous plugs Inhalation of aspergillus spores produces type 1 hypersensitivity reaction in the bronchial wall. [3] Aspergillosis has two main pathological types: superficial and deep. In superficial variety there is superficial invasion of aspergillus into the bronchial lining producing inflammation. There is productive cough with large amounts of thick green sputum and it might produce thick yellow mucus plugs. [1]
Haemoptysis [1] This is the commonest manifestation of pulmonary aspergilloma. [5] It is also seen in chronic granulomatous disease. [2]
Fever Fever may be low grade, it may be high grade if bronchopneumonia develops. [1] Low grade evening pyrexia may be associated with night sweats in the chronic granulomatous form giving the same picture as in tuberculosis. [2]
Shortness of breath There is progressive damage to the lung tissue due to the fibrosis, ultimately ends up with progressive exertional dyspnoea. [4]
Weight loss Pulmonary aspergillosis result in chronic complications such as chronic necrotizing Aspergillosis pneumonia/ chronic necrotizing pulmonary aspergillosis. These chronic patients present with weight loss. [1]
History of asthma Increased risk of aspergillosis is present in patients with bronchial asthma. [2]
History of immunedefeciency chronic debilitating illness, immunosuppression therapy or advanced age like conditions more vulnerable to get the disseminated disease. [6]
History of exposure to moldy grain Disease is acquired through the inhalation of spores. It is not transmitted from one person to the other. [2]
History of tuberculosis and lung carcinoma Aspergillosis able to invade the damaged lung tissues easily, Therefore these people are particularly vulnerable. [4]
References
  1. MANN B, PASHA MA. Allergic Primary Pulmonary Aspergillosis and Sch?nlein--Henoch Purpura Br Med J [online] 1959 Jan 31, 1(5117):282-283 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992387
  2. HUGHES FA, GOURLEY RD, BURWELL JR. Primary Pulmonary Aspergillosis: Report of an Unusual Case Successfully Treated by Lobectomy Ann Surg [online] 1956 Jul, 144(1):138-144 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1465289
  3. Farmer's lung and pulmonary aspergillosis. Br Med J [online] 1968 Dec 7, 4(5631):597-598 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1912510
  4. STEVENSON JG, REID JM. Broncho-pulmonary Aspergillosis Br Med J [online] 1957 Apr 27, 1(5025):985-986 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1973331
  5. CHEN JC, CHANG YL, LUH SP, LEE JM, LEE YC. Surgical treatment for pulmonary aspergilloma: a 28 year experience Thorax [online] 1997 Sep, 52(9):810-813 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758650
  6. CABRAL FC, MARCHIORI E, ZANETTI G, TAKAYASSU TC, MANO CM. Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report Cases J [online] :40 [viewed 15 September 2014] Available from: doi:10.1186/1757-1626-2-40

Examination

Fact Explanation
Febrile Temperature may be low grade, but if complicated with lung abscess, pneumonia etc. patients can have high grade fever. [1]
Clubbing Long term fibrosis of the lung [1] can result in bronchiectasis [5] that will cause clubbing of fingers. Allergic bronchopulmonary aspergillosis is associated with central bronchiectasis. [6]
Pallor Due to the chronic nature of the disease. [4]
Ankle oedema Cor pulmonale [2] (heart failure due to lung disease) and heart failure due to disseminated disease can present with peripheral oedema.
Tachepnea, dyspnoea [1] Increased respiratory rate occurs especially with invasive disease. [1]
Wheezing [1] Oedematous airway mucosa [3] causes narrowing of the airway producing wheezing.
Features of lung fibrosis: reduced chest expansion and moments, dull percussion note, increased vocal fremitus, reduced breath sounds In the deep pathological type of aspergillosis, [5] they invade into the lung tissue producing inflammation, fibrosis, necrosis and cavitation. Mainly fibrosis is seen in upper lobes.
Features of bronchopneumonia: reduced chest expansion and moments, dull percussion note on affected area, increased vocal fremitus, reduced breath sounds Bronchopneumonia is a recognized complication of aspergillosis. [1]
References
  1. MANN B, PASHA MA. Allergic Primary Pulmonary Aspergillosis and Sch?nlein--Henoch Purpura Br Med J [online] 1959 Jan 31, 1(5117):282-283 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992387
  2. HUGHES FA, GOURLEY RD, BURWELL JR. Primary Pulmonary Aspergillosis: Report of an Unusual Case Successfully Treated by Lobectomy Ann Surg [online] 1956 Jul, 144(1):138-144 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1465289
  3. ELLIS ME, DOSSING M, AL-HOKAIL A, QADRI SH, HAINAU B, BURNIE J. Progressive chronic pulmonary aspergillosis: a diagnostic and therapeutic challenge. J R Soc Med [online] 1992 Dec, 85(12):763-764 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293772
  4. STEVENSON JG, REID JM. Broncho-pulmonary Aspergillosis Br Med J [online] 1957 Apr 27, 1(5025):985-986 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1973331
  5. CABRAL FC, MARCHIORI E, ZANETTI G, TAKAYASSU TC, MANO CM. Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report Cases J [online] :40 [viewed 15 September 2014] Available from: doi:10.1186/1757-1626-2-40
  6. KING PT. The pathophysiology of bronchiectasis Int J Chron Obstruct Pulmon Dis [online] 2009:411-419 [viewed 15 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793069

Differential Diagnoses

Fact Explanation
Tuberculosis It is important to rule out the tuberculosis [5] in chronic granulomatous disease as both can have the similar clinical features such as low grade evening pyrexia, night sweats, haemoptysis, weight loss etc. But patients with tuberculosis are more ill looking than in aspergillosis and they may have a past or family history of tuberculosis. Tuberculosis is also associated with extrapulmonary manifestations. [7] Therefore mantoux test and microscopy for acid fast bacilli are important for the differentiation. Chest x-ray findings may also similar giving the name pseudotuberculosis for the aspergillosis. [1]
Othe fungal infections such as mucor, candida Other fungal infections can also produce the same picture as in aspergillosis with lung involvement. Mucor produces long non septate irregular hyphae on tissue sections. [1] Less laterally branched. small, uniformly dense hyphae are seen in candida.
Asthma Asthma is a chronic inflammatory disorder of the airways with reversible airway obstruction and hyperresponsiveness.[2] There are extrinsic and intrinsic triggers that trigger an episode. Dust mite, pollen, smoke, respiratory tract infections are some of these triggers. In aspergillosis also, there is triggering of the asthma attacks in known asthmatics after inhalation of the spores that produces type 1 hypersensitivity reaction. [2]
Bronchiectasis In bronchiectasis, there is an abnormal and permanent dilatation of conducting airways. [6] Bronchiectasis patients often have a long-term history of cough and daily mucopurulent sputum production. In an acute exacerbation, they usually develops hemoptysis from airway damage, thick foul smelling sputum and increased sputum production over the baseline. In pneumonia, the sputum production is acute in onset and it may be rusty sputum.On examination they have wasting, pallor and clubbing. These patients are also vulnerable to get infections of the lung.[6] Bronchiectasis is a risk factor for aspergillosis. [5]
Idiopathic Pulmonary fibrosis There is progressive fibrosis due to the proliferation of the fibroblasts in the lung parenchyma. [4] They also can present the respiratory features like cough, shortness of breath and wheezing along with signs of consolidation. There will be diffuse pulmonary infiltrates on chest x-ray with associated fibrosis. [4]
Hypersensitivity Pneumonitis This occur due to the exposure to various allergens, and they present with respiratory symptoms such as cough , shortness of breath and wheezing. Sometimes they also can develop systemic features like fever and weight loss. [3] Blood allergen specific antibody level may be elevated. It may present as acute, subacute or chronic form. This occur due to the exposure to various allergens, and they present with respiratory symptoms such as cough , shortness of breath and wheezing. Sometimes they also can develop systemic features like fever and weight loss. [3] Blood allergen specific antibody level may be elevated. It may present as acute, subacute or chronic form.
References
  1. HUGHES FA, GOURLEY RD, BURWELL JR. Primary Pulmonary Aspergillosis: Report of an Unusual Case Successfully Treated by Lobectomy Ann Surg [online] 1956 Jul, 144(1):138-144 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1465289
  2. Farmer's lung and pulmonary aspergillosis. Br Med J [online] 1968 Dec 7, 4(5631):597-598 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1912510
  3. LACASSE YVES, GIRARD MéLISSA, CORMIER YVON. Recent Advances in Hypersensitivity Pneumonitis. Chest [online] 2012 July [viewed 27 June 2014] Available from: doi:10.1378/chest.11-2479
  4. GROSS THOMAS J., HUNNINGHAKE GARY W.. Idiopathic Pulmonary Fibrosis. N Engl J Med [online] 2001 August, 345(7):517-525 [viewed 27 June 2014] Available from: doi:10.1056/NEJMra003200
  5. CABRAL FC, MARCHIORI E, ZANETTI G, TAKAYASSU TC, MANO CM. Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report Cases J [online] :40 [viewed 15 September 2014] Available from: doi:10.1186/1757-1626-2-40
  6. KING PT. The pathophysiology of bronchiectasis Int J Chron Obstruct Pulmon Dis [online] 2009:411-419 [viewed 15 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793069
  7. CHERIAN A, THOMAS S. Central nervous system tuberculosis Afr Health Sci [online] 2011 Mar, 11(1):116-127 [viewed 15 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3092316

Investigations - for Diagnosis

Fact Explanation
Eosinophil count Eosinophilia is seen. [1] Sometimes it may be high as 10%. [2]
Serum IgE level Serum IgE level [4] will be elevated and may be > 1000 IU/dL.
Skin test result for A fumigatus Skin test for Aspergillus fumigatus may be positive. [4]
Sputum microscopy and culture Fungus may be found. But this has no much clinical significance. [2,4]
Bronchoscopy Bronchial secretions may reveal the presence of Aspergillus fumigatus. [1] Bronchial biopsy can be done in advanced cases where it reveals chronic inflammatory cell infiltration.
Mantoux test and microscopy for acid fast bacilli It is important to rule out the tuberculosis in chronic granulomatous disease as both can have the similar clinical features such as low grade evening pyrexia, night sweats, weight loss etc. [2]
Chest x-ray Increased hilar shadows and web like infiltrations radiating outwards are the commonest manifestations. Thick walled cavitations [4] may be present especially over the upper lobes. [2] There can be solitary dense areas surrounded by radiolucent areas in the upper lobe which is a rare pathognomonic feature. Simple aspergillomas appear as thin walled cysts with little or no surrounding parenchymal tissue and complex ones as thick walled cavities with pulmonary infiltrates. [3]
References
  1. MANN B, PASHA MA. Allergic Primary Pulmonary Aspergillosis and Sch?nlein--Henoch Purpura Br Med J [online] 1959 Jan 31, 1(5117):282-283 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992387
  2. HUGHES FA, GOURLEY RD, BURWELL JR. Primary Pulmonary Aspergillosis: Report of an Unusual Case Successfully Treated by Lobectomy Ann Surg [online] 1956 Jul, 144(1):138-144 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1465289
  3. CHEN JC, CHANG YL, LUH SP, LEE JM, LEE YC. Surgical treatment for pulmonary aspergilloma: a 28 year experience Thorax [online] 1997 Sep, 52(9):810-813 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758650
  4. CABRAL FC, MARCHIORI E, ZANETTI G, TAKAYASSU TC, MANO CM. Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report Cases J [online] :40 [viewed 15 September 2014] Available from: doi:10.1186/1757-1626-2-40

Investigations - Fitness for Management

Fact Explanation
Haemoglobin Haemoglobin may be low due to the chronic nature of the disease and attacks of haemoptysis. [1,3]
Saturation of oxygen Will be low in severe disease. due to the hypoxia. [2]
References
  1. HUGHES FA, GOURLEY RD, BURWELL JR. Primary Pulmonary Aspergillosis: Report of an Unusual Case Successfully Treated by Lobectomy Ann Surg [online] 1956 Jul, 144(1):138-144 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1465289
  2. ELLIS ME, DOSSING M, AL-HOKAIL A, QADRI SH, HAINAU B, BURNIE J. Progressive chronic pulmonary aspergillosis: a diagnostic and therapeutic challenge. J R Soc Med [online] 1992 Dec, 85(12):763-764 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293772
  3. CABRAL FC, MARCHIORI E, ZANETTI G, TAKAYASSU TC, MANO CM. Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report Cases J [online] :40 [viewed 15 September 2014] Available from: doi:10.1186/1757-1626-2-40

Investigations - Followup

Fact Explanation
Blood eosinophil count Eosinophilia is seen in allergic bronchopulmonary aspergillosis. Get reduced with the treatment. [1]
Chest x-ray Changes may be improving with the treatment. [2]
References
  1. MANN B, PASHA MA. Allergic Primary Pulmonary Aspergillosis and Sch?nlein--Henoch Purpura Br Med J [online] 1959 Jan 31, 1(5117):282-283 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992387
  2. CABRAL FC, MARCHIORI E, ZANETTI G, TAKAYASSU TC, MANO CM. Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report Cases J [online] :40 [viewed 15 September 2014] Available from: doi:10.1186/1757-1626-2-40

Investigations - Screening/Staging

Fact Explanation
Chest x-ray Above mentioned chest radiography in pulmonary aspergillosis may be reversed with the treatment [1].
Computer tomography (CT scan) CT scanning is helpful for evaluation of bronchiectasis. [2] High-resolution computed tomography (HRCT) will show an irregular, thick-walled cavity in the upper lobes and mass with soft-tissue attenuation within it and thickening of adjacent pleura. [2]
Neutrophil and lymphocyte count Defects in host defence mechanisms such as severe neutropenia, T cell deficiency favour the development of aspergillosis. [1]
References
  1. ELLIS ME, DOSSING M, AL-HOKAIL A, QADRI SH, HAINAU B, BURNIE J. Progressive chronic pulmonary aspergillosis: a diagnostic and therapeutic challenge. J R Soc Med [online] 1992 Dec, 85(12):763-764 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293772
  2. CABRAL FC, MARCHIORI E, ZANETTI G, TAKAYASSU TC, MANO CM. Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report Cases J [online] :40 [viewed 15 September 2014] Available from: doi:10.1186/1757-1626-2-40

Management - General Measures

Fact Explanation
Avoidance of the triggering factor: exposure to moldy air This is an important measure in prevention. [3]
Antipyretics Antipyretics such as paracetamol can be given to control fever. [2]
Oxygen Oxygen is required in acute situations where the patient has low oxygen saturation. Patients can develop respiratory failure even after surgical resection of aspergilloma. [1]
Management of post op complications following lung resection Bleeding, residual pleural space, bronchopleural fistula, and empyema are the common complications that need attention. [1]
References
  1. CHEN JC, CHANG YL, LUH SP, LEE JM, LEE YC. Surgical treatment for pulmonary aspergilloma: a 28 year experience Thorax [online] 1997 Sep, 52(9):810-813 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758650
  2. CABRAL FC, MARCHIORI E, ZANETTI G, TAKAYASSU TC, MANO CM. Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report Cases J [online] :40 [viewed 15 September 2014] Available from: doi:10.1186/1757-1626-2-40
  3. HOVENDEN JL, NICKLASON F, BARNES RA. Invasive pulmonary aspergillosis in non-immunocompromised patients. BMJ [online] 1991 Mar 9, 302(6776):583-584 [viewed 15 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1669401

Management - Specific Treatments

Fact Explanation
Corticisteroids These anti inflammatory drugs that are helpful in reducing the amount of sputum, control the asthmatic reactions following exposure and reducing the frequency of pulmonary infiltrates. [2]
Antifungals Amphotericin B and itraconazole are used and voriconazole, posaconazole and ravuconazole are an alternative to Aspergillus species resistant to amphotericin B. [5] Nystatin is used to treat the secondary infections due to aspergillus such as those with tuberculosis complicated with aspergillosis. [3] May be used as inhalation method or injection into the infected site. eg:- intrapleural injection,intracavitary instillation.
Hydroxystilbamidine Aspergillus fumigatus can be eliminated from the bronchial secretions using hydroxystilbamidine as an inhaled drug. [3]
Iodide, neoarsphanamine These drugs are used without much therapeutic effect. [3]
Surgical resection Cavitation, solitary dense areas in the lung, aspergilloma and other localized lesions need surgical resection. [5] Management of aspergilloma needs lung resection as it does not improves with the antifungals. [1,4] Small local thoracotomy may be helpful. [2]
Cavernostomy If the lung reserve is limited or symptoms are life threatening, cavernostomy is indicated. [4]
References
  1. HUGHES FA, GOURLEY RD, BURWELL JR. Primary Pulmonary Aspergillosis: Report of an Unusual Case Successfully Treated by Lobectomy Ann Surg [online] 1956 Jul, 144(1):138-144 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1465289
  2. Farmer's lung and pulmonary aspergillosis. Br Med J [online] 1968 Dec 7, 4(5631):597-598 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1912510
  3. STEVENSON JG, REID JM. Broncho-pulmonary Aspergillosis Br Med J [online] 1957 Apr 27, 1(5025):985-986 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1973331
  4. CHEN JC, CHANG YL, LUH SP, LEE JM, LEE YC. Surgical treatment for pulmonary aspergilloma: a 28 year experience Thorax [online] 1997 Sep, 52(9):810-813 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758650
  5. CABRAL FC, MARCHIORI E, ZANETTI G, TAKAYASSU TC, MANO CM. Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report Cases J [online] :40 [viewed 15 September 2014] Available from: doi:10.1186/1757-1626-2-40