From the Guidelines
The diagnostic criteria for chronic pulmonary aspergillosis (CPA) require a combination of clinical, radiological, and microbiological findings, including one or more cavities with or without a fungal ball, nodules, or progressive pleural thickening on chest imaging, direct evidence of Aspergillus infection, or an immunological response to Aspergillus spp., and exclusion of alternative diagnoses, all present for at least 3 months, as recommended by the European Respiratory Journal in 2016 1. The diagnosis of CPA involves a multidisciplinary approach, considering the patient's symptoms, radiological findings, and microbiological results. Key symptoms include cough, hemoptysis, weight loss, fatigue, and shortness of breath, which must persist for at least three months. Radiological evidence is crucial, typically showing:
- One or more cavities with or without a fungal ball (aspergilloma)
- Nodules
- Progressive pleural thickening on chest imaging Microbiological confirmation requires either:
- Direct evidence of Aspergillus in respiratory samples through microscopy or culture
- Serological evidence with positive Aspergillus IgG antibodies or precipitins Additionally, patients should have evidence of a pre-existing pulmonary condition, such as tuberculosis, COPD, or sarcoidosis, and other pulmonary conditions that could explain the symptoms should be excluded. The Aspergillus IgG antibody test is the most sensitive microbiological test, as stated in the Clinical Infectious Diseases journal in 2016 1. Some key points to consider in the diagnosis and management of CPA include:
- The importance of distinguishing CPA from invasive aspergillosis, which typically occurs in severely immunocompromised patients and has a more acute presentation
- The use of antifungal therapy, such as itraconazole or voriconazole, for a minimum of 6 months in patients with CCPA and symptoms or progressive loss of lung function
- The management of hemoptysis with oral tranexamic acid or bronchial artery embolization, as recommended by the Infectious Diseases Society of America in 2016 1
- The need for careful monitoring of patients with CPA, including regular follow-up and assessment of lung function, as outlined in the European Respiratory Journal in 2016 1.
From the Research
Diagnostic Criteria for Chronic Pulmonary Aspergillosis
The diagnostic criteria for chronic pulmonary aspergillosis (CPA) involve a combination of clinical, radiological, immunological, and mycological assessments 2. The key criteria include:
- Demonstration of one or more cavities with or without a fungal ball present or nodules on chest imaging
- Direct evidence of Aspergillus infection or an immunological response to Aspergillus species
- Exclusion of alternative diagnoses, although CPA and mycobacterial disease can be synchronous
Radiological Assessment
Radiological assessment plays a crucial role in the diagnosis and management of CPA. CT imaging variables such as cavity and pleural wall thickening are significant in assessing response to treatment 3. The disappearance of a fungus ball is also strongly associated with clinical and radiologic improvement.
Laboratory Tests
Laboratory tests, including serological tests, are essential in diagnosing CPA. Aspergillus antibody is elevated in over 90% of patients and is a cornerstone for CPA diagnosis 2. However, serological tests should be interpreted in conjunction with radiological confirmation of CPA 4.
Clinical Presentation
The clinical presentation of CPA can be non-specific, making diagnosis challenging. Symptoms may include breathlessness, excess wheezing, fever, chest pain, and hemoptysis 5. A high index of suspicion is necessary to diagnose CPA, especially in patients with underlying chronic lung disease.
Management
The management of CPA involves long-term antifungal therapy, which can improve symptoms and quality of life, and halt disease progression 2, 6. Surgical management may be considered in cases of diagnostic uncertainty, significant hemoptysis, or lack of response to therapy.