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For further information, see CMDT Part 36-07: Aspergillosis

Key Features

Essentials of Diagnosis

  • Most common cause of noncandidal invasive fungal infection in transplant recipients and in patients with hematologic malignancies

  • Predisposing factors

    • Leukemia

    • Hematopoietic stem cell or solid-organ transplantation

    • Corticosteroid use

    • COVID-19 coinfection

  • Lungs, sinuses, and CNS are most common disease sites

  • Serologic detection in serum or other body fluids

    • Useful for early diagnosis and treatment

    • However, multiple determinations should be done and usefulness is decreased in patients receiving anti-mold prophylaxis (ie, voriconazole or posaconazole)

General Considerations

  • Aspergillus fumigatus is the usual cause of aspergillosis, although many species of Aspergillus can cause disease

  • Clinical illness results from abnormal immune response or tissue invasion

  • Allergic bronchopulmonary aspergillosis (ABPA) occurs in persons with asthma or cystic fibrosis

  • Invasive aspergillosis

    • Usually occurs in profound immunodeficiency, particularly in patients

      • Who have undergone hematopoietic stem cell transplantation

      • With prolonged severe neutropenia

    • Can occur among critically ill immunocompetent patients

    • Tracheobronchitis and pulmonary aspergillosis have been observed in association with severe COVID-19 infection (termed COVID-19–associated pulmonary aspergillosis)

Clinical Findings

  • Allergic forms of aspergillosis

    • Occurs in patients with preexisting asthma or cystic fibrosis

    • Worsening bronchospasm

    • Fleeting pulmonary infiltrates

    • Allergic Aspergillus sinusitis produces a chronic sinus inflammation characterized by eosinophilic mucous and noninvasive hyphal elements

  • Chronic aspergillosis

    • Cough

    • Shortness of breath

    • Weight loss

    • Malaise

  • Invasive aspergillosis

    • Pulmonary disease most common

    • Invasive sinus disease

    • Has been observed in severe COVID-19 infection


  • ABPA

    • Eosinophilia

    • High levels of IgE and IgG Aspergillus precipitins in the blood

  • Chronic aspergillosis

    • Disease manifestations range from aspergillomas that develop in a lung cavity to chronic fibrosing pulmonary aspergillosis in which the majority of lung tissue is replaced with fibrosis

  • Invasive aspergillosis

    • Patchy infiltration leading to a severe necrotizing pneumonia

    • Tissue infarction (development of pleuritic chest pain and elevation of serum lactate dehydrogenase [LD])

    • Hematogenous dissemination to the CNS, skin, and other organs

    • Blood cultures have very low yield

    • Detection of galactomannan by enzyme-linked immunosorbent assay (ELISA) or Aspergillus DNA by polymerase chain reaction (PCR); multiple determinations should be done

    • Definitive diagnosis requires demonstration of Aspergillus in tissue or culture from a sterile site

    • Chest CT scan may show indicative characteristics (eg, "halo sign")


  • ABPA

    • For acute exacerbations, prednisone, 0.5 mg/kg/day orally tapered slowly over several months

    • Itraconazole, 200 mg orally once daily for 16 weeks, appears to improve pulmonary function and decrease corticosteroid requirements, although voriconazole is increasingly being used

  • Allergic aspergillus sinusitis

    • Topical corticosteroids cornerstone of therapy

    • Itraconazole is best studied agent

  • Chronic aspergillosis

    • Surgical resection remains most effective therapy for symptomatic aspergilloma

    • Other forms of chronic aspergillosis are generally treated with at least 4–6 months of oral azole therapy

      • Itraconazole, 200 mg twice daily

      • Voriconazole, 200 mg twice daily

      • Posaconazole, 300 mg daily

  • Invasive ...

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