ASPERGILLOSIS -DR NITIN WADHWANI

1. ASPERGILLOSIS
BY-DR NITIN WADHWANI

2. ASPERGILLUS INFECTION
INTRODUCTION:
• Aspergillus infections of the lung are caused by Aspergillus fumigatus
which are ubiquitous fungi found throughout nature.
• Results in disease in susceptible hosts when inhaled.
• The pathogenesis of Aspergillus infection varies with quality and
virulence of the inhaled organism and the status of the host defence
mechanisms.
• Characterised by spectrum of pathology related to an immune
response of individual to the organism.

3. ETIOLOGY:

4. IMMUNE
SYSTEM
MILD
IMMUNOCOMPR
OMISED
HYPERSENSITIVITY NORMAL
SEVERELY
IMMUNOCOMPR
OMISED
• ABPA • MYCETOMA SEMIINVASIVE
/CHRONIC
NECROTIZING
ASPERGILLOSIS
INVASIVE
PULMONARY
ASPERGILLOSIS

5. • MYCETOMA:
• Is non invasive colonization of preexisting cavity in immunologically normal
pt with cavitatory disease
• Mycetoma is a ball of coalscent mycelial hhyphae that typically colonize pre-
existing cavity.
• Clinical features :
1. Cough and expectoration
2. Hemoptysis-frequently seen in almost ½ of cases
Bleeding is usually due to friction between fungal ball and hypervascular wall
which releases endotoxins from fungus and causes type-3 reaction in cavity
wall.

7. • LOCATION :
• UPPER LOBES
• SUPERIOR SEGMENT OF LOWER LOBE

8. • TB
• SARCOIDOSIS
• BRONCHIECTASIS
• LUNG ABSCESS
• NF-1
• EMPHYSEMATOUS BULLA
PREDISPOSED PT:

9. XRAY CT SCAN
Round to oval mass of soft tissue density
lying within preexisting cavity.
Taken in supine and prone position
Air crescent sign Mass within the cavity
Decubitus xray – to demonstrate mobility
of fungal ball
Air crescent sign
Thickening of cavity wall –s/o signs of
early aspergillus infection
Mobile intracavitatory mass is
characteristic of aspergilloma.
Irregular air spaces within
Fungal strands bridging the fungus ball
&cavity wall maybe seen.
IMAGING FINDINGS:

12. D/D OF FUNGAL BALL AND
AIR CRESCENT SIGN :
Infection
Cavitating
neoplasm
Trauma
• Hydatid cyst
• Tuberculoma
• Bacterial lung
abscess
• Bronchial
adenoma
• Cystic
hamartoma
Pulmonary
hematoma

13. • Allergic aspergillosis is a result of hypersensitivity reaction that produce ABPA or
less commonly extrinsic allergic pneumonitis or Loeffler syndrome.
• It is airway disease.
• Only seen in patients with asthma and cystic fibrosis.
• There is airway colonization -> complex hypersensitivity reaction (1 > III).
ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS:
C/F:
1. Cough
2. Wheezing
3. a/s allergic symptoms

14. • Eosinophil derived inflammation (fleeting infiltration).
• Plugging of bronchial wall with mucus plugs (contain septate hyphae)
• Th2 mediated inflammation (IL-5, 4,13) of bronchial wall
• cough with sputum (hyphae)
• Longterm- Irreversible dilatation
• Bronchiectasis.
Pathogenesis:

15. • Bronchiectasis – more in upper lobe , central, proximal airways and is B/L
• Mucus plugging with hyphae can also lead to atelectatsis.
• Adherence of conidia to respiratory epithelial cells
• cellular dysfunction
• Initially cilial disruption
• The fungal colony grows,hyphae are produced invade between & through epithelialcells
• Leading to substantial tissue disruption
Pathogenesis:

16. ABPA:
CHRONIC
ABPA:
ACUTE ABPA:
TYPE I REACTION :IMMEDIATE IgE
MEDIATED
TYPE III REACTION:DELAYED IMMUNE
COMPLEX IgA MEDIATED

17. • Pathology
• Allergic bronchopulmonary aspergillosis is the result of hypersensitivity
(esp fumigatus) .
• It grows within the lumen of the bronchi, without invasion.
• The hypersensitivity initially causes bronchospasm and bronchial wall
• Ultimately, there is bronchial wall damage with loss of muscle and bronchial
in bronchiectasis (typically central bronchiectasis) 7.
• Both types I and III allergic reactions have been implicated 4.

18. XRAY CT SCAN
Non segmental consolidation in upper
lobe
Bronchiectasis
Lobar collapse Mucoid impaction
Branching thick tubular opacity bronchial wall thickening: common
Pul cavitation cavitation: 10%
Hyperinflated lung fields
Gloved finger sign
Central bronchiectasis
ACUTE ABPA:

20. Gloved finger sign
:

25. CHRONIC ABPA:
IMAGING FEATURES:
• Bronchiectasis :
1. Bronchial wall thickening
2. Tramline shawdows
3. Ring formation
• Fibrosis: linear fibrotic band , can also cause traction bronchiectasis
• Loss of volume in upper lobe

26. A clinical staging system has been developed :
•stage I: acute
•stage II: remission
•stage III: recurrent exacerbation
•stage IV: steroid-dependent asthma
•stage V: pulmonary fibrosis
Major and minor criteria have also been established .
•major criteria
• clinical
• asthma (approximately 90% of patient may have asthma )
• radiographic features
• pulmonary opacities (transient or chronic)
• central bronchiectasis
• immune system
• blood eosinophilia
• immediate skin reactivity to Aspergillus antigen (elevated IgG and/or IgE against A.
fumigatus)
• increased serum IgE (>1000 IU/ml)
•minor criteria
• fungal elements in sputum
• expectoration of brown plugs/flecks
• delayed skin reactivity to fungal antigens

27. This form typically occurs in patients with a depressed immune system, but not as profoundly
immunocompromised as bone marrow patients who more frequently develop angioinvasive
aspergillosis. Patients are typically middle-aged. Risk factors, therefore, include 1-3:
•corticosteroids - most common systemic immunodepressant 3
•diabetes mellitus
•alcoholism
•chronic liver disease
•malnutrition
SEMI-INVASIVE(CHRONIC
NECROTIZING ASPERGILLOSIS)

28. IMAGING
FEATURES :
• AREA OF CONSOLIDATION IN UPPER LOBE
• PROGRESSES TO THICK WALLED CAVITY
• ADJACENT PLEURAL THICKENING .

30. • CONFINED TO IMMUNOCOMPROMISED HOST.
INVASIVE PULMONARY
ASPERGILLOSIS:
IMAGING FEATURES:
• MULTIPLE/ SINGLE ILLDEFINED OPACITIES
• DIFFUSE B/L CONSOLIDATION
• LARGE WEDGE SHAPED PLEURAL BASED LESION
• CAVITATION OF NODULE
• AIR CRESCENT SIGN

31. IMAGING FEATURES:
CT SCAN:
• 1-3 CM NODULES
• SEGMENTAL CONSOLIDATION
• CT HALO SIGN :ggo around the
nodules