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Discussion

Differential Diagnosis

Chronic Pulmonary Aspergillosis vs Allergic Bronchopulmonary Aspergillosis (ABPA). 

Discussion

Chronic Pulmonary Aspergillosis clinically can manifest as aspergilloma, aspergillus nodules, chronic cavitary pulmonary aspergillosis or chronic fibrosing pulmonary aspergillosis. Although the pathogenesis is not completely understood, there are predisposing conditions such as pulmonary tuberculosis, asthma, COPD, and a history of pulmonary malignancy. In patients with a history of asthma, nodules are more commonly seen with or without cavitation. Representative histopathology shows necrotic debris with central fungal hyphae accompanied by a granulomatous inflammation and scattered multinucleated giant cells which are not present in the patients sample.

Clinically, patients may present with a cough, fatigue, worsening dyspnea, chest infection or an exacerbation of their asthma. Radiologic features show cavitary lesions localized to the upper lobes of the lungs. The differential diagnoses for these patients include carcinoma of the lung, coccidioidal infection, or other fungal infections. Diagnosis is confirmed with positive Aspergillus IgG serology. Bronchoscopy is used for patients with negative fungal cultures. The mainstay of treatment is anti-fungals (Itraconazole and Voriconazole). 

ABPA is a rare clinical hypersensitivity reaction to Aspergillus fumigatus, occurring in just 2.5% of asthma patients. Clinically, patients often present with a chronic productive cough, poorly controlled asthma, and shortness of breath. Diagnosis is supported with both serologic and radiologic findings. Serologic findings include elevated serum IgE (>1000 IU/ml), eosinophilia (>2000/mm3) and detection of specific Aspergillus IgE/IgG antibodies. Radiologic findings on chest CT and Chest XRAY include central bronchiectasis, mucoid plugs, non-specific hyperinflated lungs and parenchymal infiltrates.

The mainstay of treatment of ABPA is systemic corticosteroids. However, antifungal treatment may help decrease exacerbations. The presence of mucoid material with eosinophilic micro-abscesses, septate hyphae, and radiologic impression of a RUL infiltrate concerning for a mucous plug are supportive of ABPA. While eosinophilia is present, testing for specific aspergillus IgE/IgG antibodies may be helpful to confirm the diagnosis.

References 

Akuthota P, et al. Treatment of allergic bronchopulmonary aspergillosis. Retrieved from UpToDate.

Camuset J, Nunes H, Dombret MC, et al. Treatment of chronic pulmonary aspergillosis by voriconazole in nonimmunocompromised patients. Chest 2007; 131:1435.

Chupp, Geoffrey. Fishman’s Pulmonary Diseases and Disorders. Chapter 48: Allergic Bronchopulmonary Aspergillosis (Mycosis) and Severe Asthma with Fungal Sensitivity. 2015.

Denning, David. Harrison’s Principles of Internal Medicine. Chapter 241: Aspergillosis. 2012.

Muldoon EG, Sharman A, Page ID, et al. Aspergillus nodules; another presentation of chronic pulmonary aspergillosis. BMC Pulm Med 2016.

Schweer KE, Bangard C, Hekmat K, Cornely OA. Chronic pulmonary aspergillosis. Mycoses 2014; 57:257.

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