Jewkes J, Kay PH, Paneth M, Citron KM.
Pulmonary aspergilloma: analysis of prognosis in relation to haemoptysis and survey of treatment.
Thorax. 1983 Aug;38(8):572-8. doi: 10.1136/thx.38.8.572.
Abstract/Text
From 1956 to 1980 85 patients were admitted to the Brompton Hospital, London, with pulmonary aspergilloma. The mean follow-up period was 8.7 years and 85% of patients were followed for five years or until death if this was earlier. There were 41 deaths, 27 from respiratory causes: 11 from pneumonia, six from chronic respiratory failure, seven after surgery for aspergilloma, and three from haemoptysis. Medical treatment alone was given to 36 patients, of whom three died of haemoptysis. Systemic antifungal treatment was given to 18 patients without benefit. Intracavitary antifungals were helpful in three out of 10 patients. Surgical resection was performed in 41 patients, of whom three (7%) died after operation and a further six (15%) developed major complications. Cavernostomy was performed in nine patients considered unfit for resection; four died after operation. Haemoptysis was absent or minor in 40 patients, of whom 19 were treated medically and 18 by resection, with similar five-year survival rates of 65% and 75%. Frank or major haemoptysis occurred in 45 patients, of whom 17 were treated medically and 23 by resection, with five-year survivals of 41% and 84% (p less than 0.02). The better survival of the surgical group in this retrospective survey may have been due to the selection of patients with better lung function and more localised pulmonary disease. Our observations suggest that surgical resection for aspergilloma should be restricted to patients with severe haemoptysis and adequate pulmonary function. In patients unfit for resection cavernostomy is hazardous.
Lee JK, Lee YJ, Park SS, Park JS, Cho YJ, Park YS, Yoon HI, Lee CT, Lee JH.
Clinical course and prognostic factors of pulmonary aspergilloma.
Respirology. 2014 Oct;19(7):1066-72. doi: 10.1111/resp.12344. Epub 2014 Jul 3.
Abstract/Text
BACKGROUND AND OBJECTIVE: There is limited data on size change during natural progression of pulmonary aspergilloma. We aimed at elucidating the clinical course and prognosis of aspergilloma according to its size change.
METHODS: A multicentre retrospective observational study was performed in 143 adult pulmonary aspergilloma patients with serial chest computed tomography images. The clinical course and risk of haemoptysis according to the size change of the cavity or mass of aspergillomas was evaluated.
RESULTS: Median follow-up duration was 5.1 years. The size of aspergillomas changed in 39.2% of study subjects. Decreased and increased volumes of aspergilloma were observed in 13.3% and 25.9%, respectively. Patients with decreased volume had significantly higher C-reactive protein, and more severe bronchiectasis and tuberculosis-destroyed lung. Clinically significant haemoptysis occurred in 50.3% of patients and was significantly associated with the cavity and mass volume of aspergilloma, but not the extent of volume change. A mean cavity diameter of more than 22 mm and a mass diameter of more than 18 mm increased the risk of clinically significant haemoptysis.
CONCLUSIONS: A significant portion of pulmonary aspergilloma changed size in our population. The prevalence of clinically significant haemoptysis was associated with absolute size of cavity and mass of aspergilloma.
© 2014 Asian Pacific Society of Respirology.
Walsh TJ, Anaissie EJ, Denning DW, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Segal BH, Steinbach WJ, Stevens DA, van Burik JA, Wingard JR, Patterson TF; Infectious Diseases Society of America.
Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America.
Clin Infect Dis. 2008 Feb 1;46(3):327-60. doi: 10.1086/525258.
Abstract/Text
Denning DW, Cadranel J, Beigelman-Aubry C, Ader F, Chakrabarti A, Blot S, Ullmann AJ, Dimopoulos G, Lange C; European Society for Clinical Microbiology and Infectious Diseases and European Respiratory Society.
Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management.
Eur Respir J. 2016 Jan;47(1):45-68. doi: 10.1183/13993003.00583-2015.
Abstract/Text
Chronic pulmonary aspergillosis (CPA) is an uncommon and problematic pulmonary disease, complicating many other respiratory disorders, thought to affect ~240 000 people in Europe. The most common form of CPA is chronic cavitary pulmonary aspergillosis (CCPA), which untreated may progress to chronic fibrosing pulmonary aspergillosis. Less common manifestations include: Aspergillus nodule and single aspergilloma. All these entities are found in non-immunocompromised patients with prior or current lung disease. Subacute invasive pulmonary aspergillosis (formerly called chronic necrotising pulmonary aspergillosis) is a more rapidly progressive infection (<3 months) usually found in moderately immunocompromised patients, which should be managed as invasive aspergillosis. Few clinical guidelines have been previously proposed for either diagnosis or management of CPA. A group of experts convened to develop clinical, radiological and microbiological guidelines. The diagnosis of CPA requires a combination of characteristics: one or more cavities with or without a fungal ball present or nodules on thoracic imaging, direct evidence of Aspergillus infection (microscopy or culture from biopsy) or an immunological response to Aspergillus spp. and exclusion of alternative diagnoses, all present for at least 3 months. Aspergillus antibody (precipitins) is elevated in over 90% of patients. Surgical excision of simple aspergilloma is recommended, if technically possible, and preferably via video-assisted thoracic surgery technique. Long-term oral antifungal therapy is recommended for CCPA to improve overall health status and respiratory symptoms, arrest haemoptysis and prevent progression. Careful monitoring of azole serum concentrations, drug interactions and possible toxicities is recommended. Haemoptysis may be controlled with tranexamic acid and bronchial artery embolisation, rarely surgical resection, and may be a sign of therapeutic failure and/or antifungal resistance. Patients with single Aspergillus nodules only need antifungal therapy if not fully resected, but if multiple they may benefit from antifungal treatment, and require careful follow-up.
Copyright ©ERS 2016.
深在性真菌症のガイドライン作成委員会：深在性真菌症の診断・治療ガイドライン2014.
Mason: Murray and Nadel’s Textbook of Respiratory Medicine, 5th ed.
日本医真菌学会：日本アスペルギルス症の診断・治療ガイドライン2015.
Franquet T, Müller NL, Giménez A, Guembe P, de La Torre J, Bagué S.
Spectrum of pulmonary aspergillosis: histologic, clinical, and radiologic findings.
Radiographics. 2001 Jul-Aug;21(4):825-37. doi: 10.1148/radiographics.21.4.g01jl03825.
Abstract/Text
Aspergillosis is a serious pathologic condition caused by Aspergillus organisms and is frequently seen in immunocompromised patients. At computed tomography (CT), saprophytic aspergillosis (aspergilloma) is characterized by a mass with soft-tissue attenuation within a lung cavity. The mass is typically separated from the cavity wall by an airspace ("air crescent" sign) and is often associated with thickening of the wall and adjacent pleura. CT findings in allergic bronchopulmonary aspergillosis consist primarily of mucoid impaction and bronchiectasis involving predominantly the segmental and subsegmental bronchi of the upper lobes. Aspergillus necrotizing bronchitis may manifest as an endobronchial mass, obstructive pneumonitis or collapse, or a hilar mass. Bronchiolitis is characterized by centrilobular nodules and branching linear or nodular areas of increased attenuation ("tree-in-bud" pattern). Obstructing bronchopulmonary aspergillosis mimics allergic bronchopulmonary aspergillosis at CT and manifests as bilateral bronchial and bronchiolar dilatation, large mucoid impactions, and diffuse lower lobe consolidation caused by postobstructive atelectasis. Characteristic CT findings in angioinvasive aspergillosis consist of nodules surrounded by a halo of ground-glass attenuation ("halo sign") or pleura-based, wedge-shaped areas of consolidation. Although imaging findings in pulmonary aspergillosis may be nonspecific, in the appropriate clinical setting, familiarity with the CT findings may suggest or even help establish the diagnosis.
Gotway MB, Dawn SK, Caoili EM, Reddy GP, Araoz PA, Webb WR.
The radiologic spectrum of pulmonary Aspergillus infections.
J Comput Assist Tomogr. 2002 Mar-Apr;26(2):159-73. doi: 10.1097/00004728-200203000-00001.
Abstract/Text
Aspergillus infections may be categorized by specific radiographic patterns, the patient's immunologic status, and the presence or absence of preexisting structural lung disease. General patterns include invasive aspergillosis (both vascular and airway invasive varieties and acute tracheobronchitis), semiinvasive aspergillosis (including allergic bronchopulmonary aspergillosis and hypersensitivity pneumonitis), mycetoma, allergic aspergillosis, and obstructing bronchial aspergillosis. Knowledge of these various radiographic patterns as well as the immune derangements that accompany these infections may allow proper diagnosis.
Hammerman KJ, Christianson CS, Huntington I, Hurst GA, Zelman M, Tosh FE.
Spontaneous lysis of aspergillomata.
Chest. 1973 Dec;64(6):679-9. doi: 10.1378/chest.64.6.697.
Abstract/Text
Setianingrum F, Rautemaa-Richardson R, Shah R, Denning DW.
Clinical outcomes of patients with chronic pulmonary aspergillosis managed surgically.
Eur J Cardiothorac Surg. 2020 Nov 1;58(5):997-1003. doi: 10.1093/ejcts/ezaa137.
Abstract/Text
OBJECTIVES: Surgical resection is one treatment modality for chronic pulmonary aspergillosis (CPA), and sometimes a preoperative presumption of lung cancer turns out to be CPA. We have audited our surgical experience with regard to risk factors for relapse, and the value of postoperative monitoring of Aspergillus-immunogolubulin G (IgG) titres.
METHODS: All patients with CPA surgically treated at National Aspergillosis Centre (NAC), Manchester, UK (2007-2018), were retrospectively evaluated. Surgical procedures, underlying disorders, Aspergillus-IgG titres (ImmunoCap) and antifungal therapy were evaluated for symptom control, operative complications, CPA relapse and mortality.
RESULTS: A total of 61 patients with CPA (28 males, 33 females) were operated on primarily for antifungal therapy failure (51%, n = 31) and presumed lung malignancies (38%, n = 23). Procedures included lobectomy (64%, n = 39), wedge resection (28%, n = 17), segmentectomy (n = 3), pneumonectomy (n = 3) and decortication (n = 2). Overall, 25 (41%) patients relapsed, 26 months (standard deviation: 24.8 months) after surgery. Antifungal therapy before surgery (P = 0.002) or both before and after surgery (P = 0.005) were protective for relapse. The relapse rate within 3 years after surgery (33%, n = 20) was higher than the 3-10 years after surgery (8%, n = 5). At the end of follow-up, the median Aspergillus-IgG titre was lower than at relapse in 12 patients (67 vs 126 mg/l) (P = 0.016).
CONCLUSIONS: Surgery in these selected patients with CPA resulted in favourable outcomes. Relapse is common after surgical treatment of CPA but can be minimized with antifungal therapy, emphasizing the importance of an accurate diagnosis prior to surgery.
© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
Patterson TF, Thompson GR 3rd, Denning DW, Fishman JA, Hadley S, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Nguyen MH, Segal BH, Steinbach WJ, Stevens DA, Walsh TJ, Wingard JR, Young JA, Bennett JE.
Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America.
Clin Infect Dis. 2016 Aug 15;63(4):e1-e60. doi: 10.1093/cid/ciw326. Epub 2016 Jun 29.
Abstract/Text
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
Published by Oxford University Press for the Infectious Diseases Society of America 2016. This work is written by (a) US Government employee(s) and is in the public domain in the US.
Lejay A, Falcoz PE, Santelmo N, Helms O, Kochetkova E, Jeung M, Kessler R, Massard G.
Surgery for aspergilloma: time trend towards improved results?
Interact Cardiovasc Thorac Surg. 2011 Oct;13(4):392-5. doi: 10.1510/icvts.2011.265553. Epub 2011 Jul 5.
Abstract/Text
Surgery of aspergilloma has been renowned to be technically challenging and has a high complication rate. We have already demonstrated an improved outcome as a result of a reduction in complex cases related to history of tuberculosis. In this paper we will evaluate whether this time trend has continued during recent years. Initial presentation and postoperative outcome of 33 patients who underwent surgical treatment between 1998 and 2009 were reviewed and compared with two previous reports (group 1: 55 patients from 1974 to 1991; group 2: 12 patients from 1992 to 1997). Underlying disease was tuberculosis in 15% of patients (57% in group 1, 17% in group 2), and 12% of patients had complex aspergillomas (80% in group 1, 41% in group 2). Postoperatively, there was no mortality (5% in group 1, 0% in group 2). Morbidity decreased progressively in terms of bleeding (44% in group 1, 9% in group 2, and 6% in recently, accrued patients), of pleural space problems (47%, 18% and 12%, respectively), and of prolonged hospital stay (32%, 8% and 6%, respectively). With a decreased postoperative complications rate after resection, contemporary surgery of aspergilloma is safe and offers satisfactory early and long-term results.
Chen QK, Jiang GN, Ding JA.
Surgical treatment for pulmonary aspergilloma: a 35-year experience in the Chinese population.
Interact Cardiovasc Thorac Surg. 2012 Jul;15(1):77-80. doi: 10.1093/icvts/ivs130. Epub 2012 Apr 11.
Abstract/Text
The surgical treatment of pulmonary aspergilloma is challenging and controversial. This study was designed to evaluate the clinical profile, indications and surgical outcomes of pulmonary aspergilloma operated on in our institute. A total of 256 patients with pulmonary aspergilloma underwent surgical treatment from 1975 to 2010. The patients were divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160). The principal underlying lung disease was tuberculosis (71.1%). The surgical procedures consisted of 212 lobectomies in both groups; eight cavernoplasties, 10 bilobectomies, 16 pneumonectomies and six thoracoplasties in Group B; four segmentectomies and six wedge resections in Group A. Postoperative complications occurred in 40 patients (15.6%). The major complications were residual pleural space (3.9%), prolonged air leak (3.1%), bronchopleural fistula (1.6%), excessive bleeding (1.6%), respiratory insufficiency (1.9%) and empyema (1.2%). No intraoperative deaths occurred. The overall mortality within 30 days post-operation was 1.2%, occurring only in Group B. There was no statistically significant difference in the postoperative morbidity between Groups A and B (P = 0.27). With the good selection of patients, meticulous surgical techniques and good postoperative management, aggressive surgical treatment with anti-fungal therapy for pulmonary aspergilloma is safe and effective, and can achieve favourable outcomes.
Corr P.
Management of severe hemoptysis from pulmonary aspergilloma using endovascular embolization.
Cardiovasc Intervent Radiol. 2006 Sep-Oct;29(5):807-10. doi: 10.1007/s00270-005-0329-0.
Abstract/Text
PURPOSE: To determine the effectiveness of endovascular embolization as a temporizing measure in the management of severe hemoptysis caused by intracavitary pulmonary aspergilloma.
METHODS: Patients presenting with hemoptysis, estimated to be more than 300 ml in the preceding 24 hr, in whom a radiological diagnosis of pulmonary aspergilloma was made on chest radiographs and/or computed tomography of the chest were subjected to bronchial and systemic arteriography and embolization using triacryl microspheres.
RESULTS: Twelve patients with upper lobe intracavitary aspergillomas were managed with embolization. In 11 patients hemoptysis stopped within 24 hr and with no recurrence over the next 4 weeks. In 1 patient hemoptysis persisted and an upper lobe lobectomy was performed.
CONCLUSION: Embolization of bronchial and systemic arteries is an effective method for treating acute severe hemoptysis from intracavitary aspergillomas, allowing the patient time to recover for definitive surgical management.
Al-Shair K, Atherton GT, Harris C, Ratcliffe L, Newton PJ, Denning DW.
Long-term antifungal treatment improves health status in patients with chronic pulmonary aspergillosis: a longitudinal analysis.
Clin Infect Dis. 2013 Sep;57(6):828-35. doi: 10.1093/cid/cit411. Epub 2013 Jun 20.
Abstract/Text
BACKGROUND: Chronic pulmonary aspergillosis (CPA) is an infectious disease that progressively destroys lung tissue. To date, no longitudinal data on the efficacy of antifungal treatment on health status in CPA patients exist.
METHODS: Using the standardized St George's Respiratory Questionnaire, the health status of 122 patients with was assessed at baseline and quarterly over 12 months. The score range was 0-100, where higher score indicates worse heath status, and a change of ≥4 was deemed the minimal clinically important difference. Lung function, body mass index, Medical Research Council dyspnea scale, disease severity, and demographic data were reported.
RESULTS: Mean age of patients was 59 years, and 45% were female. Overall, patients with CPA had substantial health status impairment at baseline. After treatment, 47%-50% gained substantial health improvement with a mean reduction of score of 14 at both 6 and 12 months, whereas 32% deteriorated with a mean rise of score of 11 and 14 after 6 and 12 months of treatment and observation, respectively, and 21% were not much different (stable). Patients gained therapeutic benefit irrespective of their illness severity where >50% of those who had "poor" and "very poor" status at baseline improved with score reduction of ≥4 after 6 months of treatment. Replicating this analysis using a health status category, we found that at least 50% of patients with a "poor/very poor" health status category at baseline improved significantly to "fair" or "good/very good" categories. Side effects burdened health status considerably. In multivariate analysis, dyspnea and disease severity significantly defined health status impairment.
CONCLUSIONS: Antifungal therapy improved health status and prevented CPA progression in most patients.
Dupont B.
Itraconazole therapy in aspergillosis: study in 49 patients.
J Am Acad Dermatol. 1990 Sep;23(3 Pt 2):607-14. doi: 10.1016/0190-9622(90)70263-h.
Abstract/Text
Itraconazole, 200 to 400 mg once daily, was administered to 49 patients with different types of aspergillosis: pulmonary aspergilloma (14 patients), chronic necrotizing pulmonary aspergillosis (14), and invasive aspergillosis (21). Itraconazole was prescribed alone or in combination or after treatment with amphotericin B and flucytosine. Of 14 aspergilloma patients, 2 were cured and 8 had symptomatic improvement. In chronic necrotizing pulmonary aspergillosis, 7 of 14 patients were cured and 6 improved significantly. In invasive aspergillosis treatment failed in 6 patients and 15 were cured. Itraconazole can be an alternative to amphotericin B in the treatment of invasive aspergillosis and chronic necrotizing pulmonary aspergillosis. In aspergilloma itraconazole may be useful in inoperable cases.
Campbell JH, Winter JH, Richardson MD, Shankland GS, Banham SW.
Treatment of pulmonary aspergilloma with itraconazole.
Thorax. 1991 Nov;46(11):839-41. doi: 10.1136/thx.46.11.839.
Abstract/Text
In a 12 month open study of itraconazole in pulmonary aspergilloma nine patients received oral itraconazole 200 mg daily for six months followed by further itraconazole or observation for a further six months. There was no change in the serum IgG specific for Aspergillus fumigatus (mean (SE) change -4% (10%)) or symptoms of chronic cough and haemoptysis. In two of the three patients who continued treatment beyond six months symptoms and radiographic appearances improved and a temporary reduction in A fumigatus specific IgG occurred in one patient. Further experience of the effects of longer treatment are needed before oral itraconazole can be recommended for aspergilloma.
Giron J, Poey C, Fajadet P, Sans N, Fourcade D, Senac JP, Railhac JJ.
CT-guided percutaneous treatment of inoperable pulmonary aspergillomas: a study of 40 cases.
Eur J Radiol. 1998 Oct;28(3):235-42. doi: 10.1016/s0720-048x(97)00148-4.
Abstract/Text
OBJECTIVE: To treat symptomatic pulmonary aspergilloma in patients who were not considered to be operable.
MATERIAL AND METHODS: Forty patients were treated by CT-guided percutaneous injection of amphotericin paste, the aim being to fill the cavity completely and create an anaerobic environment for the aspergillus. The aspergillomas had developed after bacillary infection and pulmonary fibrosis. Surgery was contra-indicated in these patients because of severe respiratory failure. The authors detail the method of preparation of the paste and the technique of percutaneous injection.
RESULTS: Hemoptysis ceased in all 40 patients, with a follow-up ranging from 6 to 28 months; six patients were also treated with bronchial embolization. In 26 patients, the aspergilloma disappeared and serum tests for aspergillus became negative. Complete disappearance of both the aspergilloma and the cavity was obtained in three patients.
CONCLUSION: This technique appears to be a valuable contribution to non-surgical treatment of inoperable patients with pulmonary aspergilloma, but study should be continued in a larger series to define the exact indications and the interaction with other treatments which have recently been introduced.
