Diagnosis and treatment of chronic pulmonary aspergillosis: clinical guidelines of European Society for Clinical Microbiology and Infectious Diseases and European Respiratory Society

Abstract

Chronic pulmonary aspergillosis (CPA) is infrequent respiratory disease which is difficult for diagnosis and can complicate other respiratory diseases and conditions. Currently, there are about 240,000 CPA patients in Europe. The most prevalent variant of CPA is chronic cavitary pulmonary aspergillosis (CCPA) which could progress to chronic fibrosing pulmonary aspergillosis (CFPA) when is untreated. Aspergillus nodules and single aspergilloma are less frequent clinical variants of this disease. All clinical variants of aspergillosis could be found in nonimmunocompromised patients with different underlying pulmonary disorders. Subacute invasive pulmonary aspergillosis, which was referred to as chronic necrotising pulmonary aspergillosis, is the most rapidly progressive clinical variant of the infection (< 3 months); it is typically diagnosed in moderately immunocompromised patients and should be treated as invasive aspergillosis. Diagnosis and management of CPA patients were previously described in sporadic guidelines. Due to this, expert group have been convened to develop clinical, radiological and microbiological guidelines. Diagnosis of CPA requires a combination of the following criteria existing for 3 months or more: one or more cavities in the lungs with or without fungal mass inside or nodules found on radiological examination; direct evidence of Aspergillus infection (using microscopic examination or biopsy culturing) or immunological response to Aspergillus spp. and exclusion of alternative diseases. Antibodies against Aspergillus spp. (precipitins) are increased in > 90% of patients. Aspergilloma should be resected if technically possible; videoassisted thoracic surgery is preferable. Chronic cavitary pulmonary aspergillosis requires longterm oral antifungal therapy to improve the patients' health and respiratory symptoms, to arrest haemoptysis and prevent the disease progression. Azole serum concentration and drug interaction should be thoroughly monitored to avoid toxic effects. Haemoptysis could be arrested using therapy with tranexamic acid or bronchial artery embolization; surgical resection of the lung is rarely required. Haemoptysis could indicate therapeutic failure and / or resistance to antifungals. Patients with a single Aspergillus nodule need antifungal therapy only if surgical resection is impossible. Antifungal therapy could be beneficial in patients with multiple Aspergillusis nodules; these patients need careful followup.