PRIMARILY AFFECTS LUNGS CAUSING 4 MAIN SYNDROMES :
1. ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS
2. CHR. NECROTIZING ASPERGILLUS PNEUMONIA
3. ASPERGILLOMA
4. INVASIVE ASPERGILLOSIS &
5. SYSTEMIC SPREAD IN SEVERELY IMMUNOCOMPROMIZED PATIENTS
Medical Care: The treatment of invasive aspergillosis and chronic necrotizing aspergillosis differs significantly from the treatment of ABPA and aspergilloma.
" Invasive aspergillosis
o This is often rapidly progressive and has a high mortality rate; therefore, preventive therapy and rapid institution of therapy in patients in whom invasive aspergillosis is suggested may be lifesaving. Prophylactic antifungal therapy and the use of laminar air flow (LAF) or high-efficiency particulate air (HEPA) filtration of patient rooms in patients who receive bone marrow transplant and other high-risk patients may prevent invasive aspergillosis. In patients with solid organ transplant, especially lung, in whom Aspergillus is cultured from sputum without evidence of pneumonia (colonization), inhaled amphotericin B may be administered.
o When high-risk patients develop a compatible clinical picture, empiric treatment for aspergillosis should be started as diagnostic testing is undertaken. Voriconazole is now considered the drug of choice for invasive aspergillosis because of better tolerance and improved survival with its use when compared with amphotericin. Amphotericin B or amphotericin B lipid formulations may be considered as empiric therapy in critically ill patients if the clinical picture could be compatible with mucormycosis, as voriconazole is ineffective for mucor. Caspofungin has also been approved for treatment of invasive aspergillosis in patients who are unable to tolerate or are resistant to other therapies.Initial combination therapy is usually not indicated and should generally be reserved for treatment failures.
o If possible, the level of immunosuppression should be decreased. For example, patients who are neutropenic may receive growth factors (ie, granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor), and patients with certain types of transplant, in which transplanted organ dysfunction will not be life threatening (eg, renal transplant), may have immunosuppressive medications, including corticosteroids, reduced or discontinued.
o Combination antifungal therapy sometimes may be used for patients whose disease progresses on a single drug. Concomitant therapy with azole antifungals and amphotericin is controversial because the azole antifungals decrease amphotericin-binding sites and may therefore diminish its effectiveness. Be alert to the possibility of diminished effectiveness of amphotericin in any patient who has received prior treatment with an azole antifungal, including voriconazole, itraconazole, fluconazole, or ketoconazole. Newer antifungal azoles are under study (eg, ravuconazole) and may be available for compassionate use in patients in whom other therapies have failed. Posaconazole, a new triazole, was recently approved by the US Food and Drug Administration (FDA).
" Aspergilloma
o Treatment is considered when patients become symptomatic, usually with hemoptysis. Surgical resection is curative but may not be possible in patients with limited pulmonary function. Oral itraconazole may provide partial or complete resolution of aspergillomas in 60% of patients. Successful intracavitary treatment, using CT-guided percutaneously placed catheters to instill amphotericin alone or in combination with other drugs, including acetylcysteine and aminocaproic acid, has been reported in small numbers of patients.
o Bronchial artery embolization may be used for life-threatening hemoptysis in patients thought to have insufficient pulmonary reserve to tolerate surgery or in patients with recurrent hemoptysis (eg, patients with cystic fibrosis in whom hemoptysis may be related to underlying bronchiectasis with or without aspergilloma). Bronchial artery embolization requires a skilled and experienced radiologist because localizing the abnormal vessel(s) may be challenging. Because the anterior spinal arteries may originate from the bronchial vessels, serious neurologic complications, although rare, may occur.
" Allergic bronchopulmonary aspergillosis
o This is a hypersensitivity reaction that requires treatment with oral corticosteroids. Inhaled steroids are not effective.
o It may be beneficial to add oral itraconazole to steroids in patients with recurrent or chronic ABPA. This may allow more rapid resolution of infiltrates and symptoms, facilitating steroid tapering or lowering the needed maintenance corticosteroid dosage.
o Patients who have associated allergic fungal sinusitis benefit from surgical resection of obstructing nasal polyps and inspissated mucus in addition to corticosteroid therapy. Nasal washes with amphotericin have also been used.
" Chronic necrotizing Aspergillus pneumonia
o Treatment consists of therapy with voriconazole, or in some cases itraconazole (if expense is an issue), caspofungin, or amphotericin B or amphotericin lipid formulation. A prolonged course of therapy to radiographic resolution is needed. In addition, reduction or elimination of immunosuppression should be attempted, if possible.
o Surgical resection may be considered when localized disease fails to respond to antifungal therapy.
Surgical Care:
" Invasive aspergillosis and chronic necrotizing aspergillosis
o Surgical resection is a consideration for localized disease that has failed to respond to prolonged antifungal therapy.
o Aspergillomas may occasionally form in areas of necrotizing pneumonia. These necrotic areas may bleed, sometimes massively, necessitating consideration of surgical resection.
o Patients may be high-risk surgical candidates because of underlying disease, coagulopathy, or thrombocytopenia and limited pulmonary reserve.
" Aspergilloma
o Surgical resection may be considered for massive hemoptysis if pulmonary function is sufficient enough for this sort of intervention. Assessment of operative risk necessitates obtaining pulmonary function studies, arterial blood gas determinations, and, possibly, split lung function studies (eg, quantitative perfusion lung scanning). Because aspergilloma occurs in cavitary areas, the affected lung may not be functional.
o Surgical resection may be difficult because of scarring, pleural adhesion, and the presence of abnormal vasculature.
" Allergic bronchopulmonary aspergillosis
o Areas of mucoid impaction may have a masslike appearance and are sometimes resected as an undiagnosed lung mass; however, steroid therapy and oral itraconazole therapy are preferred.
o Allergic fungal sinusitis usually requires endoscopic sinus surgery to improve drainage.
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DRUG TREATMENT :
1. AMPHOTERICIN B
2. ITRACONAZOLE
3. CASPOFUNGIN
4. VORICONAZOLE
5. POSACONAZOLE
STEROIDS IN ALLERGIC REACTIONS :
1. PREDNISOLONE