Aspergillosis B44.9

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

aspergillus infection

Definition
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Mould infection mostly caused by Aspergillus spp.

Pathogen
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Aspergillus species, e.g. Aspergillus fumigatus, Aspergillus flavus, Aspergillus niger, Aspergillus terreus (see also moulds).

Occurrence/Epidemiology
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The main reservoir of Aspergillus spp. is long-term stored plant material (hay, compost, potting soil). Aspergillus is found ubiquitously. Frequently occurring as lung and CNS complications in immunocompromised patients.

Etiopathogenesis
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Weakness of the immune system, malignant tumours, 15% in patients with cystic fibrosis (E84.8), long-term therapy with glucocorticoids, cytostatics, after X-ray radiation; in patients with stem cell transplantation.

Clinical features
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Local infection:

  • Infestation of skin, mucous membranes and nails see below Onychomycosis (primary cutaneous or mucosal aspergillosis).
  • Further local infestation of the auditory canal, ear and sinuses possible.

System infections:

  • In case of systemic infestation, infection occurs by inhalation of the spores. The lungs are primarily affected:
    • Aspergilloma that spreads in a cavity of the lung.
    • Allergic bronchopulmonary aspergillosis (ABPA) with bronchial asthma (IgE-mediated allergic bronchial asthma can also occur independently of ABPA).
    • Invasive Pulmonary Aspergillosis and Aspergillus Pneumonia
  • In cases of pronounced polyätiological immunodeficiency (e.g. AIDS, organ transplantation), haematogenic spreading with infestation of several internal organs, pyemic-septic course with metastasis mainly in the heart muscle, endocardium, central nervous system and kidneys may occur.
  • Primary cutaneous neonatal aspergillosis in premature infants: rare but increasing disease which is mainly observed in immature infants. It is caused by small local injuries and insufficient keratinization of the immature organism. Clinically there are 1 or more grossly consistent, surface smooth, reddish papules.

Exogenous-allergic alveolitis: Aspergillus species can (rather rarely) have a triggering effect here.

Diagnosis
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  • Pathogen detection microscopically and culturally in tissue samples.
  • Detection of Aspergillus antibodies in the Aspergillus/Galactomann antigen test from serum, bronchial secretion or cerebrospinal fluid.
  • In case of organ infestation: X-ray, spiral CT, Ak detection, brocnhoscopy with detection of aspergillus in bronchial secretion.
  • Histological detection in biopsies.

General therapy
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For these balls of fungus spreading in lung caverns, purely drug-based therapy is ineffective. Surgical removal of aspergillomas if present.

External therapy
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Broad-spectrum antifungals, e.g. Ciclopiroxalamine (e.g. Batrafen cream) or Clotrimazole tincture 2% or Tolnaftat (e.g. Tinatox cream, Tonoftal cream)

Internal therapy
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For systemic invasive aspergillosis:

  • Therapy of the 1st choice is voriconazole (adults and children > 12 years). 2 times/day (every 12 hours) 6 mg/kg bw. Maintenance dose from day 2: 2 times/day 4 mg/kg bw i.v. ).
  • Alternatively: Amphotericin B (e.g. Ampho-Moronal 100 mg) 4 times/day 1 tbl. for 2-4 weeks or liposomal amphotericin B (e.g. AmBisome®) initial 1 mg/kg bw i.v., if necessary gradually increasing to 3 mg/kg bw 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 Kps. p.o. for 2-5 months.
  • Alternative: In case of failure of all above mentioned therapies, try caspofungin (e.g. Cancidas®: initial 70 mg/day i.v. up to 7 days after the symptoms have subsided).

Prophylaxis
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Posaconazole is used prophylactically in severely immunocompromised patients.

Note(s)
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There is increasing evidence of azole resistance in Aspergillus species (Dabas Y et al. 2018).

Literature
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  1. Dabas Y et al (2018) "Emergence of azole resistant Aspergillus fumigatus from immunocompromised hostsin
    India". Antimicrobial agents Chemother pii: AAC.02264-17.
  2. Helmi M (2003) Aspergillus infection in lung transplant recipients with cystic fibrosis: risk factors and outcomes comparison to other types of transplant recipients. Chest 123: 800-808
  3. Klotz D et al (2013) Primary kuntane aspergillosis in an extremely immature premature baby. Dermatologist 64: 664-665
  4. Tarrand JJ et al (2003) Diagnosis of invasive septate mold infections. A correlation of microbiological culture and histologic or cytologic examination. At J Clin Pathol 119: 854-858

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020