What are the lung exam findings in patients with aspergillosis?

Lung Exam Findings in Aspergillosis

The most important lung exam findings in aspergillosis include wheezing, crackles, decreased breath sounds, and occasionally stridor or rhonchi, though findings vary significantly based on the specific form of aspergillosis and disease stage.

Types of Pulmonary Aspergillosis and Associated Exam Findings

Invasive Pulmonary Aspergillosis (IPA)

• Clinical presentation: Fever, cough, dyspnea, chest pain, and hemoptysis 1
• Lung exam findings:
  • Decreased breath sounds over areas of consolidation
  • Crackles (especially in areas of consolidation)
  • Occasionally wheezing if bronchial involvement
  • Pleural friction rub if pleural involvement
  • Hypoxemia on pulse oximetry 1

Chronic Pulmonary Aspergillosis (CPA)

• Clinical presentation: Chronic productive cough, dyspnea, weight loss, fatigue, hemoptysis
• Lung exam findings:
  • Crackles over affected areas
  • Decreased breath sounds over cavities
  • Bronchial breath sounds near cavities
  • Signs of pleural thickening (dullness to percussion, decreased tactile fremitus) 1

Aspergilloma (Fungal Ball)

• Clinical presentation: May be asymptomatic or present with hemoptysis
• Lung exam findings:
  • Often minimal findings on auscultation
  • Occasionally crackles over the affected area
  • Decreased breath sounds if large aspergilloma 1, 2

Allergic Bronchopulmonary Aspergillosis (ABPA)

• Clinical presentation: Wheezing, productive cough, dyspnea
• Lung exam findings:
  • Prominent wheezing (often diffuse)
  • Rhonchi due to mucoid impaction
  • Crackles in areas of bronchiectasis
  • Signs of airflow obstruction 2

Tracheobronchial Aspergillosis

• Clinical presentation: Cough, dyspnea, stridor
• Lung exam findings:
  • Stridor (if tracheal involvement)
  • Localized wheezing
  • Rhonchi
  • Signs of bronchial obstruction (decreased breath sounds) 1

Diagnostic Considerations

Imaging Correlation with Exam Findings

• CT findings that may correlate with auscultatory findings:
  • Angioinvasive form: Macronodules >1cm (may have halo sign), consolidation
  • Bronchoinvasive form: Tracheal/bronchial wall thickening, centrilobular nodules with tree-in-bud appearance 1
  • Allergic form: Mucoid impaction and bronchiectasis 2

When to Suspect Aspergillosis Based on Exam

• Consider aspergillosis when finding:
  • Persistent crackles and wheezing despite antibacterial therapy
  • Localized decreased breath sounds with history of cavitary lung disease
  • New-onset wheezing in patients with asthma or cystic fibrosis
  • Respiratory symptoms in immunocompromised patients 1

Special Considerations

Immunocompromised Patients

• Exam findings may be subtle or atypical
• Maintain high suspicion with any new respiratory symptoms
• May have rapid progression from minimal to severe findings 1

COPD Patients

• May present with increased wheezing or rapid decline in lung function
• Consider Aspergillus sensitization assessment when refractory wheezing is present 3

Pitfalls in Physical Examination

• Exam findings are non-specific and must be correlated with:
  • Clinical history (immunosuppression, prior lung disease)
  • Imaging findings (CT preferred over chest X-ray)
  • Laboratory tests (galactomannan, Aspergillus IgG/IgE)
  • Microbiological or histopathological confirmation 1

Monitoring Response to Treatment

• Improvement in exam findings should be expected with successful therapy:
  • Decreased crackles
  • Resolution of wheezing
  • Improved air entry
  • However, some findings may persist due to permanent structural changes (e.g., bronchiectasis, cavities) 1

Remember that lung exam findings in aspergillosis are often non-specific and must be interpreted in the appropriate clinical context. Definitive diagnosis requires a combination of clinical, radiological, and microbiological/histopathological evidence.