Figures
- Fig. 1.—
a) Thoracic computed tomography scan of a patient with antibiotic resistant neutropenic fever showing a nodular infiltrate in the lingula. When initial antimycotic therapy failed, the patient was scheduled for lung resection. b) The intraoperative appearence during lung resection in the same patient: the invasive fungal infection infiltrates the pericardium. c) Histology of the resected lingula confirmed invasive aspergillosis with fungal hyphae infiltrating the surrounding tissue.
Tables
- Table 1—
Value of different diagnostic methods in invasive pulmonary aspergillosis
Sensitivity Specificity Comments Thoracic CT scan Halo/air crescent >80 60–98 Specificity only assessed in a few studies, findings depend on the disease stage Serum Galactomannan Antigen Latex agglutination (Pastorex®) 13–95 86–100 Cross reactivity against penicillium ELISA (Platelia®) 90–93 95–98 ppv 87–93, npv 95–98, False positive rate 8–14 To measure 1–3 times weekly BDG-ELISA 16–90 76–100, ppv 59, npv 97 PCR 100, 65–92, ppv 15–44, npv 100 Useful to exclude aspergillus Bronchoscopy with BAL Culture 43 100 Use of Sabouard medium preferred Galactomannan antigen 0–80 65–95 Highly variable results PCR 67–100 55–95, ppv 20–46, npv 93–100 Useful to exclude aspergillus Data are presented as % unless otherwise stated
CT: computed tomography
ELISA: Enzyme-linked immunosorbent assay
BDG: (1–3)‐β‐d‐glucan
PCR: Polymerase chain reaction
BAL: bronchoalveolar lavage
ppv: positive predictive value
npv: negative predictive value
- Table 2—
Medical therapy in invasive pulmonary aspergillosis
Dosage Response % Comments Amphotericine B Desoxycholate 1–1.5 mg·Kg−1 33–54 Mortality of 64–90% Fewer side effects in continuous 24 h infusion Local instillation possible Not effective in prophylaxis Colloid dispersion 3–4 mg·Kg−1 38–48 Less nephrotoxicity, but severe side effects as fever, chills, hypoxia Lipid complex 4.8 mg·Kg−1 42–67 Less nephrotoxicity, but chills, rigor, fever Liposomal 1–3 (–6) 30–60 Less nephrotoxicity Mg·Kg−1 Less breakthrough infections Reduced aspergillus colonization Azoles Itraconazole Oral 400–600 mg 39–66 Side effects: nausea and vomiting Better resorption as oral solution i.v. 200 mg 48 Long term therapy induces resistance Voriconazole 50–75 Visual, hepatic, and dermal side effects FDA approval pending Posaconazole 53 FDA approval pending Racuvonazole Only animal studies Echinocandins Caspofungin (MK-0991) 41–45 Preliminary data from clinical trials FK 463 In clinical trials LY-303366 In clinical trials Papulacandins In development Acidic terpenoids In development FDA: Food and Drug Administration
- Table 3—
Surgery in invasive pulmonary aspergillosis (IPA): indication and risks
Indication for Surgery Localiszed or multilocular IPA Early stage IPA Failure of antifungal therapy Planned immunosuppression, e.g. HDC or SCT Haemoptysis Perioperative mortality 14% (24 of 165 patients) Postoperative complications 7% (12 of 165 patients) (nonfatal) Recurrent mould infection 16% (27 of 165 patients) Fungal relapse post SCT 8% (3 of 35 patients) HDC: high dose chemotherapy
SCT: stem cell transplantation
