Case 1: Old PT with Aspergilloma

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Case 1: Old PT with Aspergilloma

  1. 1. Prof.S.Sundar Unit
  2. 2. Present histroy <ul><li>c/o hemoptysis-10epi 50-100ml/epi </li></ul><ul><li>c/o cough and sputum-1month </li></ul><ul><li>No h/o fever </li></ul><ul><li>No h/o breathlessness </li></ul><ul><li>No h/o chest pain </li></ul><ul><li>No h/o LOW/LOA </li></ul><ul><li>Noh/o hematuria </li></ul><ul><li>No h/o hematemesis </li></ul><ul><li>No h/o anticoagulation intake </li></ul>
  3. 3. Past histroy <ul><li>No past h/o hemoptysis </li></ul><ul><li>h/o treated PT one year before </li></ul><ul><li>Smoker </li></ul><ul><li>Not a k/c of DM/SHT/CAD/ COPD </li></ul><ul><li>Non alcoholic </li></ul>
  4. 4. General examination <ul><li>Conscious, oriented </li></ul><ul><li>Afebrile </li></ul><ul><li>Halitosis + </li></ul><ul><li>No pallor </li></ul><ul><li>No clubbing </li></ul><ul><li>No cyanosis </li></ul><ul><li>No pedal edema </li></ul><ul><li>Not dyspneic </li></ul><ul><li>No significant lymphadenopathy </li></ul>
  5. 5. Systemic examination <ul><li>R.S-trachea midline </li></ul><ul><li>flat chest </li></ul><ul><li>cavernous BBS + left </li></ul><ul><li>infraclavicular region </li></ul><ul><li>B/L coarse crepts + </li></ul><ul><li>Other system examination- normal </li></ul>
  6. 6. Investigations <ul><li>CBC- WNL </li></ul><ul><li>RFT -WNL </li></ul><ul><li>Urine R/E- WNL </li></ul><ul><li>ECG- WNL </li></ul><ul><li>Sputum AFB-negative </li></ul><ul><li>SputumC/S-Klebsiella sensitive to amikacin,ciprofloxcine </li></ul><ul><li>Serum IgE level- normal </li></ul>
  7. 13. <ul><li>Chest x-ray </li></ul><ul><li>left UL cavity with homogenous </li></ul><ul><li>opacity within the cavity with </li></ul><ul><li>semilunar air shadow </li></ul><ul><li>CT Thorax </li></ul><ul><li>conglumerate fibrotic mass </li></ul><ul><li>Lesion doesnot enhance with </li></ul><ul><li>contrast-S/O Aspergilloma </li></ul>
  8. 14. <ul><li>Fungal c/s </li></ul><ul><li>A.fumigatus grown in culture </li></ul><ul><li>KOH mount </li></ul><ul><li>branching hyphal fragment of </li></ul><ul><li>aspergillus seen </li></ul><ul><li>Aspergillus precipitin test-positive </li></ul><ul><li>HIV/VDRL-nonreactive </li></ul>
  9. 15. DIAGNOSIS <ul><li>Old treated pulmonary TB </li></ul><ul><li>Left upper lobe cavity </li></ul><ul><li>Aspergilloma </li></ul>
  10. 16. <ul><li>CT-Surgery opinion </li></ul><ul><li>left upper lobe aspergilloma </li></ul><ul><li>Advised medical </li></ul><ul><li>management </li></ul><ul><li>Chest medicine opinion </li></ul><ul><li>Advised oral antifungal </li></ul>
  11. 17. TREATMENT <ul><li>C.Itraconazole 100mg 2bd </li></ul><ul><li>Packed RBC one unit </li></ul><ul><li>Bronchodilator </li></ul><ul><li>Inj.adrenochrome </li></ul><ul><li>Inj.ciprofloxcin 200mg iv bd </li></ul><ul><li>Bronchial arterial embolization </li></ul>
  12. 18. <ul><li>DISCUSSION ON ASPERGILLOSIS </li></ul>
  13. 19. CAUSED BY <ul><li>A. fumigatus-most common </li></ul><ul><li>A.flavus </li></ul><ul><li>A.niger </li></ul><ul><li>A.terreus </li></ul><ul><li>A nidulans-immunocompromised </li></ul>
  14. 20. SPECTRUM OF PULMONARY ASPERGILLOSIS <ul><li>HYPERSENSITIVITY REACTION </li></ul><ul><li>Allergic bronchial asthma </li></ul><ul><li>ABPA </li></ul><ul><li>Extrinsic allergic alveolitis </li></ul><ul><li>Bronchocentric granulomatosis </li></ul><ul><li>INVASIVE INFECTION </li></ul><ul><li>Invasive bronchial aspergillosis </li></ul><ul><li>Chronic necrotizing pulmonary aspergillosis </li></ul><ul><li>Invasive pulmonary aspergillosis </li></ul><ul><li>Bronchial stump aspergillosis </li></ul><ul><li>SAPROPHYTIC GROWTH IN PREEXISTING CAVITY </li></ul><ul><li>SIMPLE COLONISATION </li></ul>
  15. 21. ASPERGILLOMA <ul><li>Saprophytic colonization of Aspergillus in parenchymal lung cavity </li></ul><ul><li>Fungal ball lie free within the cavity or attached to cavitywall by granulation tissue </li></ul>
  16. 22. SECONDARY ASPERGILLOMA <ul><li>Colonization and proliferation of fungus in a preexisting lung cavity </li></ul><ul><li>Tuberculosis cavity </li></ul><ul><li>Sarcoidosis </li></ul><ul><li>Histoplasmosis </li></ul><ul><li>Blastomycosis </li></ul><ul><li>AIDS pneumonia </li></ul><ul><li>Lung abscess </li></ul>
  17. 23. <ul><li>Bronchiectasis </li></ul><ul><li>Ankylosing spondylitis </li></ul><ul><li>Rheumatoid nodules </li></ul><ul><li>Pulmonary infarction </li></ul><ul><li>Lung cancer </li></ul>
  18. 24. PRIMARY ASPERGILLOMA <ul><li>Proliferation of aspergillus in bronchial tree leading to pulmonary cavity </li></ul><ul><li>CAUSES </li></ul><ul><li>Invasive pulmonary aspergillosis </li></ul><ul><li>Chronic necrotizing pulmonary aspergillosis </li></ul><ul><li>Allergic bronchopulmonary aspergillosis </li></ul>
  19. 25. CHEST X-RAY <ul><li>Solid round mass within the cavity </li></ul><ul><li>Partially surrounded by radiolucent crescent-MONOD’S sign </li></ul><ul><li>Movement of fungal ball in the cavity </li></ul><ul><li>Preexisting tuberculous cavities the most common predisposing condition </li></ul>
  20. 26. CT- SCAN THORAX <ul><li>Globules of gas are often seen within the interstices of the hyphal mass </li></ul><ul><li>CT ANGIOGRAPHY </li></ul><ul><li>Identifying hypertrophic bronchial arteries that supply cystic wall of aspergilloma </li></ul>
  21. 27. SPUTUM CULTURES <ul><li>Positive in 50% of the cases </li></ul><ul><li>Not sensitivity and specific </li></ul><ul><li>PRECIPITATING ANTIBODIES </li></ul><ul><li>Positive in 95% of the cases </li></ul>
  22. 28. MANAGEMENT OPTIONS <ul><li>Systemic or local antifungal </li></ul><ul><li>Surgical resection </li></ul><ul><li>Bronchial arterial embolization </li></ul><ul><li>Conservative management with carefull followup </li></ul>
  23. 29. INTRACAVITARY ANTIFUNGAL AGENTS <ul><li>CT guided percuteaneous instillation of AMB </li></ul><ul><li>Endobronchial instillation of AMB via fiberoptic bronchoscopy </li></ul><ul><li>Indication-solitary aspergilloma with severe hemoptysis and contraindication for surgery </li></ul>
  24. 30. ORAL ANTIFUNGAL-ITRACONAZOLE <ul><li>Active against A.fumigatus </li></ul><ul><li>High tissue penetration into the lung </li></ul><ul><li>Dose 200-400mg/d for 6-18 months </li></ul><ul><li>Symptomatic and radiographic improvement in twothird of patients </li></ul><ul><li>Major limitations- it works slowly </li></ul><ul><li>recurrence after discontinuation </li></ul><ul><li>not usefull in severe hemoptysis </li></ul>
  25. 31. SURGICAL RESECTION <ul><li>Indications </li></ul><ul><li>severe hemoptysis </li></ul><ul><li>sarcoidosis </li></ul><ul><li>chronic immunosuppression </li></ul><ul><li>increasing titer of specific IgG </li></ul><ul><li>single large cavity </li></ul>
  26. 32. BRONCHEAL ARTERIAL EMBOLIZATION <ul><li>Management of hemoptysis </li></ul><ul><li>Only temporarily effective </li></ul><ul><li>RADIATION THERAPY </li></ul><ul><li>Indicated in recurrent lifethreatening hemoptysis after BAE </li></ul>
  27. 33. DIFFERENTIAL DIAGNOSIS <ul><li>Lung cancer </li></ul><ul><li>Pulmonary abscess </li></ul><ul><li>wegener’s granulomatosis </li></ul><ul><li>Bloodclot in a preexisting cavity </li></ul><ul><li>Disintegrating hydatid cyst </li></ul>
  28. 34. PREDICTORS OF POOR PROGNOSIS <ul><li>Progressive increase in size </li></ul><ul><li>Multiple aspergillomas </li></ul><ul><li>Severe underlying lung disease </li></ul><ul><li>Immunosuppressive therapy </li></ul><ul><li>AIDS </li></ul><ul><li>Sarcoidosis </li></ul><ul><li>Rising Aspergillus specific IgG Titer </li></ul><ul><li>Repetitive episodes of severe hemoptysis </li></ul>
  29. 35. Take home messsage <ul><li>Aspergilloma-Rare disease </li></ul><ul><li>BUT NOT VERY RARE </li></ul><ul><li>DISEASE </li></ul><ul><li>Important firstline D.D for evaluation of hemoptysis </li></ul>
  30. 36. <ul><li>THANK U </li></ul>

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