title: Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management.
abstract: Chronic pulmonary aspergillosis (CPA) is an uncommon and problematic pulmonary disease, complicating many other respiratory disorders, thought to affect ~240 000 people in Europe. The most common form of CPA is chronic cavitary pulmonary aspergillosis (CCPA), which untreated may progress to chronic fibrosing pulmonary aspergillosis. Less common manifestations include: Aspergillus nodule and single aspergilloma. All these entities are found in non-immunocompromised patients with prior or current lung disease. Subacute invasive pulmonary aspergillosis (formerly called chronic necrotising pulmonary aspergillosis) is a more rapidly progressive infection (<3 months) usually found in moderately immunocompromised patients, which should be managed as invasive aspergillosis. Few clinical guidelines have been previously proposed for either diagnosis or management of CPA. A group of experts convened to develop clinical, radiological and microbiological guidelines. The diagnosis of CPA requires a combination of characteristics: one or more cavities with or without a fungal ball present or nodules on thoracic imaging, direct evidence of Aspergillus infection (microscopy or culture from biopsy) or an immunological response to Aspergillus spp. and exclusion of alternative diagnoses, all present for at least 3 months. Aspergillus antibody (precipitins) is elevated in over 90% of patients. Surgical excision of simple aspergilloma is recommended, if technically possible, and preferably via video-assisted thoracic surgery technique. Long-term oral antifungal therapy is recommended for CCPA to improve overall health status and respiratory symptoms, arrest haemoptysis and prevent progression. Careful monitoring of azole serum concentrations, drug interactions and possible toxicities is recommended. Haemoptysis may be controlled with tranexamic acid and bronchial artery embolisation, rarely surgical resection, and may be a sign of therapeutic failure and/or antifungal resistance. Patients with single Aspergillus nodules only need antifungal therapy if not fully resected, but if multiple they may benefit from antifungal treatment, and require careful follow-up.
authors.affiliation: The National Aspergillosis Centre, University Hospital of South Manchester, The University of Manchester and the Manchester Academic Health Science Centre, Manchester, UK ddenning@manchester.ac.uk.
authors.forename: David W
authors.initials: DW
authors.lastname: Denning
authors.affiliation: Service de Pneumologie, AP-HP, Hôpital Tenon and Sorbonne Université, UPMC Univ Paris 06, Paris, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Cadranel
authors.affiliation: Dept of Diagnostic and Interventional Radiology, University Hospital CHUV, Lausanne, Switzerland.
authors.forename: Catherine
authors.initials: C
authors.lastname: Beigelman-Aubry
authors.affiliation: Dept of Infectious Diseases, Hospices Civils de Lyon, Lyon, France Centre International de Recherche en Infectiologie (CIRI), INSERM U1111, CNRS UMR5308, Lyon, France.
authors.forename: Florence
authors.initials: F
authors.lastname: Ader
authors.affiliation: Center of Advanced Research in Medical Mycology, Dept of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
authors.forename: Arunaloke
authors.initials: A
authors.lastname: Chakrabarti
authors.affiliation: Dept of Internal Medicine, Ghent University, Ghent, Belgium Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.
authors.forename: Stijn
authors.initials: S
authors.lastname: Blot
authors.affiliation: Dept of Internal Medicine II, Division of Infectious Diseases, University Hospital Würzburg, Julius-Maximilians-University, Würzburg, Germany.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Ullmann
authors.affiliation: Dept of Critical and Respiratory Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece.
authors.forename: George
authors.initials: G
authors.lastname: Dimopoulos
authors.forename: Christoph
authors.initials: C
authors.lastname: Lange
mesh_terms: D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D001229:Aspergillosis, Allergic Bronchopulmonary / Q000150:complications / Q000175:diagnosis / Q000276:immunology / Q000628:therapy; D001981:Bronchial Arteries; D001999:Bronchoscopy; D002908:Chronic Disease; D019468:Disease Management; D004621:Embolization, Therapeutic / Q000379:methods; D006469:Hemoptysis / Q000209:etiology / Q000628:therapy; D006801:Humans; D007121:Immunocompetence; D016867:Immunocompromised Host; D055744:Invasive Pulmonary Aspergillosis / Q000150:complications / Q000175:diagnosis / Q000276:immunology / Q000628:therapy; D008168:Lung / Q000000981:diagnostic imaging* / Q000601:surgery; D008271:Mycetoma / Q000150:complications / Q000175:diagnosis / Q000276:immunology / Q000628:therapy; D055732:Pulmonary Aspergillosis / Q000150:complications / Q000175:diagnosis* / Q000276:immunology / Q000628:therapy; D020775:Thoracic Surgery, Video-Assisted; D014057:Tomography, X-Ray Computed; D014148:Tranexamic Acid / Q000627:therapeutic use
chemical_list: D000933:Antifibrinolytic Agents; D000935:Antifungal Agents; D014148:Tranexamic Acid