What is the treatment for Aspergilloma (fungal infection caused by Aspergillus species)?

From the Guidelines

Aspergilloma treatment typically involves surgical resection for symptomatic cases, particularly when patients experience hemoptysis, or antifungal medications such as voriconazole or itraconazole for patients who are poor surgical candidates. The decision to treat aspergilloma is based on the presence of symptoms, with symptomatic cases often requiring intervention to prevent complications such as hemoptysis or to improve quality of life.

Treatment Options

• Surgical resection is considered the definitive treatment for symptomatic aspergillomas, especially in cases of life-threatening hemoptysis, and is usually performed through procedures like lobectomy or segmentectomy to remove the fungal ball and surrounding affected tissue 1.
• For patients who are poor surgical candidates due to compromised lung function or other comorbidities, alternative approaches include antifungal medications such as voriconazole (typically 200-300mg twice daily) or itraconazole (200mg twice daily) for several months 1.
• In cases of life-threatening hemoptysis, bronchial artery embolization may be performed as a temporary measure to control bleeding.
• Some patients may benefit from intracavitary instillation of antifungals like amphotericin B directly into the fungal cavity, though this approach has variable success rates.

Considerations

• Asymptomatic aspergillomas may simply be monitored without intervention, as the risks of treatment may outweigh the benefits in the absence of symptoms.
• Treatment decisions should be individualized based on symptom severity, patient's overall health status, and lung function, as aspergillomas develop in pre-existing lung cavities often caused by tuberculosis, sarcoidosis, or other chronic lung conditions, making surgical intervention sometimes challenging due to underlying lung disease 1.

From the FDA Drug Label

Voriconazole, administered orally or parenterally, has been evaluated as primary or salvage therapy in 520 patients aged 12 years and older with infections caused by Aspergillus spp., Fusarium spp., and Scedosporium spp. The efficacy of voriconazole compared to amphotericin B in the primary treatment of acute IA was demonstrated in 277 patients treated for 12 weeks in a randomized, controlled study (Study 307/602). A satisfactory global response at 12 weeks (complete or partial resolution of all attributible symptoms, signs, radiographic/bronchoscopic abnormalities present at baseline) was seen in 53% of voriconazole treated patients compared to 32% of amphotericin B treated patients.

Treatment of Aspergilloma:

• The recommended dosing regimen for invasive aspergillosis is a loading dose of 6 mg/kg every 12 hours for the first 24 hours, followed by a maintenance dose of 4 mg/kg every 12 hours.
• The median duration of intravenous voriconazole therapy was 10 days (range 2 to 85 days), and the median duration of oral voriconazole therapy was 76 days (range 2 to 232 days) 2.
• Voriconazole has been shown to be effective in the treatment of invasive aspergillosis, with a satisfactory global response rate of 53% compared to 32% for amphotericin B 3.
• The treatment should be continued for at least 7 days, and then switched to oral formulation if the patient can tolerate it 2.

From the Research

Treatment Options for Aspergilloma

• Surgical treatment is currently the mainstay of treatment for aspergilloma, but it is associated with considerable mortality and morbidity 4.
• Alternative options exist for patients who are poor surgical candidates and for those who prefer a less invasive treatment modality.
• Systemic treatment with amphotericin B is ineffective and is not recommended as a monotherapy, but systemic azoles are effective in approximately 50-80% of patients 4.

Antifungal Agents for Invasive Aspergillosis

• Voriconazole remains the treatment of choice for invasive aspergillosis, but isavuconazole and posaconazole have similar efficacy with less toxicity 5.
• Combination therapy is used with extensive infection and in severe immunosuppression 5.
• Isavuconazole was associated with the best probability of favourable response and the best reduction mortality against invasive aspergillosis when treated with monotherapy 6.
• Liposomal amphotericin B plus caspofungin was the therapy associated with the best probability of favourable response and the best reduction mortality against invasive aspergillosis when treated with combination therapy 6.

Efficacy of Voriconazole

• Voriconazole shows excellent in vitro activity against Aspergillus spp., including itraconazole- and amphotericin B-resistant A. fumigatus isolates 7, 8.
• At 12 weeks, 52.8% of voriconazole recipients achieved a successful outcome (complete or partial response) versus 31.6% of amphotericin B recipients in a randomised, nonblind trial in 392 patients with invasive aspergillosis 7, 8.
• Voriconazole was generally well tolerated, but transient visual disturbances were common, occurring in approximately 30% of patients 7 and 44.8% of patients 8.