Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management

Author: 

David W. Denning1, Jacques Cadranel2, Catherine Beigelman-Aubry3, Florence Ader4,5, Arunaloke Chakrabarti6, Stijn Blot7,8, Andrew J. Ullmann9, George Dimopoulos10 and Christoph Lange11–14 on behalf of the European Society for Clinical Microbiology and Infectious Diseases and European Respiratory Society Affiliations: 1 The National Aspergillosis Centre, University Hospital of South Manchester, The University of Manchester and the Manchester Academic Health Science Centre, Manchester, UK. 2 Service de Pneumologie, AP-HP, Hôpital Tenon and Sorbonne Université, UPMC Univ Paris 06, Paris, France. 3 Dept of Diagnostic and Interventional Radiology, University Hospital CHUV, Lausanne, Switzerland. 4 Dept of Infectious Diseases, Hospices Civils de Lyon, Lyon, France. 5 Centre International de Recherche en Infectiologie (CIRI), INSERM U1111, CNRS UMR5308, Lyon, France. 6 Center of Advanced Research in Medical Mycology, Dept of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India. 7 Dept of Internal Medicine, Ghent University, Ghent, Belgium. 8 Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia. 9 Dept of Internal Medicine II, Division of Infectious Diseases, University Hospital Würzburg, Julius-Maximilians-University, Würzburg, Germany. 10Dept of Critical and Respiratory Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece. 11Division of Clinical Infectious Diseases and German Center for Infection Research (DZIF) Tuberculosis Unit, Research Center Borstel, Borstel, Germany. 12International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany. 13Dept of Medicine, Karolinska Institute, Stockholm, Sweden. 14Dept of Medicine, University of Namibia School of Medicine, Windhoek, Namibia. Correspondence: David W. Denning, Education and Research Centre, University Hospital of South Manchester,Southmoor Road, Manchester, M23 9LT, UK. E-mail: [email protected]
Eur Respir J 2015

Abstract: 

Chronic pulmonary aspergillosis (CPA) is an uncommon and problematic pulmonary disease, complicating many other respiratory disorders, thought to affect ∼240000 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.