Aspergillus spp may cause a variety of pulmonary diseases, depending on immune status and the presence of underlying lung disease. These manifestations range from invasive pulmonary aspergillosis in severely immunocompromised patients, to chronic necrotizing aspergillosis in patients with chronic lung disease and/or mildly compromised immune systems. Aspergilloma is mainly seen in patients with cavitary lung disease, while allergic bronchopulmonary aspergillosis is described in patients with hypersensitivity to Aspergillus antigens. Recent major advances in the diagnosis and management of pulmonary aspergillosis include the introduction of non-invasive tests, and the development of new antifungal agents, such as azoles and echinocandins, that significantly affect the management and outcome of patients with pulmonary aspergillosis. This review provides a clinical update on the epidemiology, risk factors, clinical presentation, diagnosis and management of the major syndromes associated with pulmonary aspergillosis.

Invasive pulmonary aspergillosis is an emerging serious infection in patients with COPD. The majority of these patients have advanced COPD and/or on corticosteroid therapy. The clinical and radiological presentation is nonspecific. High index of suspicion is necessary for the timely treatment of these patients.

Solitary pulmonary nodules (SPNs) are increasingly detected with the widespread use of chest computed tomography (CT) scans. The primary goal of the evaluation of these nodules is to determine whether they are malignant or benign. Clinical factors such as older age, tobacco smoking and current or remote history of malignancy increase the pre-test likelihood of malignancy. Radiological features of the SPN based on chest CT with high resolution cuts are critical in differentiating between benign or malignant lesions. These features include size, change in size, the presence and pattern of calcification, edge characteristics, attenuation, and contrast enhancement. SPNs that are stable in size for >2 years and those with benign pattern of calcification do not need further studies. Lesions with clear change in size are malignant until proven otherwise and require tissue diagnosis. Frequently, the aetiology of the SPN following chest CT scan remains indeterminate and requires further evaluation. The approach to the management of indeterminate SPN ranges between observation with repeat chest CT scan, further diagnostic studies such as positron emission tomography (PET) scan, or invasive procedures to obtain tissue diagnosis. These procedures include bronchoscopy, transthoracic needle aspirate, and resection by video assisted thoracoscopy or thoracotomy. Determination of which approach to follow depends on the pre-test probability of malignancy, whether the patient is a surgical candidate, and the patient's informed preferences. This article reviews the radiological features of the SPN and their value in differentiating between benign and malignant lesions. This is followed by discussion of the different approaches to the management of the SPN after initial characterisation by chest CT scan, including the benefits and limitations of the different diagnostic studies.

Ethylene glycol is found in many household products and is a common toxic ingestion. Acute ingestions present with altered sensorium and an osmolal gap. The true toxicity of ethylene glycol is mediated by its metabolites, which are responsible for the increased anion gap metabolic acidosis, renal tubular damage, and crystalluria seen later in ingestions. Early intervention is key; however, diagnosis is often delayed, especially in elderly patients presenting with altered mental status. There are several laboratory tests which can be exploited for the diagnosis, quantification of ingestion, and monitoring of treatment, including the lactate and osmolal gaps. As methods of direct measurement of ethylene glycol are often not readily available, it is important to have a high degree of suspicion based on these indirect laboratory findings. Mainstay of treatment is bicarbonate, fomepizole or ethanol, and, often, hemodialysis. A validated equation can be used to estimate necessary duration of hemodialysis, and even if direct measurements of ethylene glycol are not available, monitoring for the closure of the anion, lactate, and osmolal gaps can guide treatment. We present the case of an elderly male with altered mental status, acute kidney injury, elevated anion gap metabolic acidosis, and profound lactate and osmolal gaps.