Pulmonary Aspergillosis B44.9

Opportunistic, systemic fungal disease with a poor prognosis, occurring mainly in immunocompromised and neutropenic patients.

The entry point is usually the lungs through inhalation of mold spores. However, these can also enter via open wounds.

The skin is affected in only 11% of cases (site of manifestation of secondary disseminated aspergillosis).

First symptom is prolonged antibiotic-resistant fever.

Lungs: The lungs are affected in 80-90% of patients (interstitial pneumonia).

NNH and CNS: Infections of the nasal sinuses and CNS are observed in 5-10% of patients.

Skin involvement: Different clinical pictures are possible here: solitary necrotizing dermal plaques and nodules, subcutaneous granulomas or abscesses, persistent patchy or papular lesions, transient erythema or generalized exanthema, progressive confluent granulomas (only in immunocompetent patients) (Darr-Foit S 2017).

Primary skin involvement with solitary, necrotizing skin ulcerations covered with black eschar has also been described in leukemic children, especially at the site of inoculation, e.g., entry sites of indwelling venous catheters.

Also perform aspergillus exclusion diagnostics in case of unspecific chest x-ray under immunosuppression. Culture from biopsy, possibly frozen section (PAS staining). Detection of Aspergillus precipitins in serum or sputum culture may be negative.

Early amphotericin B (e.g. Ampho-Moronal 100 mg) 4 times/day 1 tbl. for 2-4 weeks or liposomal amphotericin B (e.g. AmBisome) initially 1 mg/day/kg bw i.v., if needed stepwise increase to 3 mg/kg bw/day i.v. Possibly combination with flucytosine (e.g. Ancotil) 150-200 mg/kg bw/day i.v. for 3-4 weeks in 4 single doses over 20-40 minutes each.

Alternatively: itraconazole (e.g. Sempera) 2 times/day 2 cps. p.o. for 2-5 months. If all above therapies fail, try caspofungin (e.g. Cancidas) initial 70 mg/day i.v. up to and including 7 days after resolution of symptoms or voriconazole up to and including 7 days after remission.

Posaconazole: treatment resistance or patients with intolerance to other systemic antifungals: 400 mg (10 ml) p.o. 2 times/day (daily dose 800 mg) or 200 mg (5 ml) p.o. 4 times/day. Duration of therapy depends on disease severity, recovery from immunosuppression if necessary, and clinical response.

Badly. Frequently septicaemic, usually fatal course with infestation of lungs, heart, liver, kidneys and CNS.

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2. Marr KA et al (2002) Aspergillosis. Pathogenesis, clinical manifestations, and therapy. Infect Dis Clin North Am 16: 875-894
3. Petraitis V et al (2003) Combination Therapy in Treatment of Experimental Pulmonary Aspergillosis: Synergistic Interaction between an Antifungal Triazole and an Echinocandin. J Infect Dis 187: 1834-1843
4. Warris A (2001) Invasive pulmonary aspergillosis associated with infliximab therapy. N Engl J Med 344: 1099-1100
5. Warris A et al (2002) Multidrug resistance in Aspergillus fumigatus. N Engl J Med 347: 2173-217