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Aspergillosis — Clinical Guidelines

Overview

Aspergillosis encompasses a spectrum of diseases caused by Aspergillus species, ranging from allergic reactions to invasive infections, primarily affecting the lungs but potentially involving other organs. 1 2

Diagnosis

Imaging: Chest CT recommended for suspected pulmonary invasive aspergillosis (IA). 1

Bronchoscopy: Bronchoalveolar lavage (BAL) with histopathological examination strongly recommended. 1

Microscopy: Direct microscopy, preferably with optical brighteners, for rapid diagnosis. 1

Culture: Essential for definitive species identification and antifungal susceptibility testing. 1

Galactomannan: Serum and BAL galactomannan assays recommended as biomarkers for IA diagnosis. 1

PCR: Considered adjunctively with other tests for enhanced sensitivity. 1

Serology: IgG antibodies and precipitins can indicate exposure but lack specificity for invasive disease. 5

Management

First-line Treatment: Isavuconazole and voriconazole for pulmonary IA. 1

Alternative Therapy: Liposomal amphotericin B as a moderately supported alternative. 1

Monitoring: Antifungal susceptibility testing advised in regions with known resistance patterns. 1

Drug Interactions: Caution with voriconazole due to potential interactions (e.g., with CYP2C19 inhibitors like lansoprazole and statins). 4

Special Populations

Immunocompromised Patients: Central nervous system aspergillosis more common; MRI and CT imaging crucial. 8

Rare Sites: Primary prostatic and renal aspergillosis require specific imaging (MRI, CT) and tailored management. 6 7

Key Recommendations

Use chest CT and bronchoscopy with BAL for diagnosis of suspected pulmonary IA. (Evidence: Strong 1)

Perform serum and BAL galactomannan testing as biomarkers for IA. (Evidence: Strong 1)

Identify Aspergillus species and perform susceptibility testing in regions with resistance. (Evidence: Strong 1)

Initiate treatment with isavuconazole or voriconazole for pulmonary IA. (Evidence: Strong 1)

Exercise caution with voriconazole due to potential drug interactions affecting metabolism. (Evidence: Moderate 4)

References

1 Ullmann AJ, Aguado JM, Arikan-Akdagli S, Denning DW, Groll AH, Lagrou K et al.. Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases 2018. link 2 Patterson TF, Thompson GR, Denning DW, Fishman JA, Hadley S, Herbrecht R et al.. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2016. link 3 Patterson TF, Thompson GR, Denning DW, Fishman JA, Hadley S, Herbrecht R et al.. Executive Summary: Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2016. link 4 Lopez JL, Tayek JA. Voriconazole-Induced Hepatitis via Simvastatin- and Lansoprazole-Mediated Drug Interactions: A Case Report and Review of the Literature. Drug metabolism and disposition: the biological fate of chemicals 2016. link 5 Faux JA, Shale DJ, Lane DJ. Precipitins and specific IgG antibody to Aspergillus fumigatus in a chest unit population. Thorax 1992. link 6 Khawand N, Jones G, Edson M. Aspergillosis of prostate. Urology 1989. link90173-8) 7 Zirinsky K, Auh YH, Hartman BJ, Rubenstein WA, Morrison HS, Sherman SJ et al.. Computed tomography of renal aspergillosis. Journal of computer assisted tomography 1987. link 8 Mikhael MA, Rushovich AM, Ciric I. Magnetic resonance imaging of cerebral aspergillosis. Computerized radiology : official journal of the Computerized Tomography Society 1985. link90003-4) 9 Rutqvist L, Lundblad G. Studies on Aspergillus fumigatus; hydrolysis of polyamino acids by mycelial filtrate and chromatographic fractionation of the filtrate. Acta veterinaria Scandinavica 1969. link

Aspergillosis