Chronic Pulmonary Aspergillosis: Notes for a Clinician in a Resource-Limited Setting Where There Is No Mycologist

Abstract

Chronic pulmonary aspergillosis (CPA) is a spectrum of several progressive disease manifestations caused by Aspergillus species in patients with underlying structural lung diseases. Duration of symptoms longer than three months distinguishes CPA from acute and subacute invasive pulmonary aspergillosis. CPA affects over 3 million individuals worldwide. Its diagnostic approach requires a thorough Clinical, Radiological, Immunological and Mycological (CRIM) assessment. The diagnosis of CPA requires (1) demonstration of one or more cavities with or without a fungal ball present or nodules on chest imaging, (2) direct evidence of Aspergillus infection or an immunological response to Aspergillus species and (3) exclusion of alternative diagnoses, although CPA and mycobacterial disease can be synchronous. Aspergillus antibody is elevated in over 90% of patients and is the cornerstone for CPA diagnosis. Long-term oral antifungal therapy improves quality of life, arrests haemoptysis and prevents disease progression. Itraconazole and voriconazole are alternative first-line agents; voriconazole is preferred for patients with contra-indications to itraconazole and in those with severe disease (including large aspergilloma). In patients co-infected with tuberculosis (TB), it is not possible to treat TB with rifampicin and concurrently administer azoles, because of profound drug interactions. In those with pan-azole resistance or intolerance or progressive disease while on oral triazoles, short-term courses of intravenous liposomal amphotericin B or micafungin is used. Surgery benefits patients with well-circumscribed simple aspergillomas and should be offered earlier in low-resource settings.

Post-tuberculosis chronic pulmonary aspergillosis: An emerging public health concern

“…It is important to note that most patients with CPA have multiple underlying lung conditions [12]. Other important non-TB underlying conditions include chronic obstructive pulmonary disease (COPD), fibrocystic sarcoidosis, pneumothorax, and other [12,21].…”

Mechanisms of triazole resistance in Aspergillus fumigatus

“…Multiple studies have attempted to approximate the global impact of aspergilloses and to discern any appreciable changes in incidence over time. Surveys have recently estimated the current burden of aspergilloses worldwide, approximating 4.8 million cases of ABPA, 3 million cases of chronic pulmonary aspergillosis (CPA) and between 250, 000 and 400, 000 cases of IA annually (Brown et al ., 2012; Bongomin et al ., 2017; CDC, 2019; Bongomin et al ., 2020). IA occurs in up to 14% of heart transplant recipients, up to 7% of bone marrow transplant recipients, and up to 10% of haematological malignancy and lung transplant patients (Eggimann et al ., 2006).…”

Chronic Pulmonary Aspergillosis in Post Tuberculosis Patients in Indonesia and the Role of LDBio Aspergillus ICT as Part of the Diagnosis Scheme

“…Detection of Aspergillus IgG in serum is the core of laboratory assessments for CPA [ 9 , 10 , 11 ]. Antibodies can be detected using various methods such as an enzyme-linked immunosorbent assay (ELISA), immunoprecipitation, complement fixation, haemagglutination, immunoblot and lateral flow assay [ 9 , 12 ]. Lateral flow assay (LFA) has been used in recent years to simplify the detection of Aspergillus IgG with fast results and minimal laboratory equipment [ 13 , 14 ].…”