AspergillosisDiagnosis and Treatment

CaseA 50 year old WM with ESRD secondary to diabetes on HD whounderwent a cadaveric renal transplant.

Immunosuppressive regimen consisted of prednisone, Mycophenolate mofetil, and cyclosporine. Patient developed thrombocytopenia and was taken off the Mycophenolate mofetil. Developed catheter-related sepsis and bacteremia due to P. aeruginosa.

The catheter was removed and he received a 2-week course of Meropenem and Ciprofloxacin then discharged.

1 month posttransplant he developed a nonproductive cough. He was maintained on prednisone and cyclosporine and was given Ganciclovir for CMV prophylaxis. He was again started on Mycophenolate mofetil.

2 months post-transplant he was readmitted to the hospital for possible rejection.

ROS was negative for cough chest pain, hemoptysis, SOB, fever and night sweats.

PE revealed that the patient was afebrile. Clear lungs. Heart sounds normal.Abdomen non tender.

CBC: WBC 5.0, Hb 10.5, Plt 49Serum Cr 3.4 BUN 70

What additional information or testing would you require?

Additional testing

Serology/AntigenEIA

CXR

High res-CT

BronchoscopyMicroBiopsy

Neg Aspergillus AbGalactomannan?

A new 3 cm round lesion in the Left lower Lung

3 well-defined round lesions in LLL

Washing Cx (+)Biopsy slides

Fig:1 Aspergilloma found at post-mortem in the lung of a child with leukemia.

Fig 2: Aspergilloma found at post-mortem in the lung of a child with leukemia. Note fungus ball occupying cavity.

AspergillosisAspergillosis is a spectrum of diseases in humans and animals caused by members of the genus Aspergillus.

These include (1)Mycotoxicosis due to ingestion of contaminated

foods (2)Allergy and sequelae to the presence of conidia

or transient growth of the organism in body orifices

(3)Colonization without extension in preformed cavities and debilitated tissues

(4)Invasive, inflammatory, granulomatous, necrotizing disease of lungs, and other organs

(5)Systemic and fatal disseminated disease.

The type of disease and severity depends upon the physiologic state of the host and the species of Aspergillus involved.

Distribution: World-wide.

Etiological Agents:

Aspergillus fumigatus, A. flavus, A. niger, A. nidulans and A. terreus.

Invasive Aspergillosis DX

Histopathologyacute angle branchingseptated nonpigmented

hyphae, measuring 2-4 microns in width

culture yielding Aspergillus sp.

Fig 3: Grocott’s methenamine silver (GMS) stained tissue section of lung showing fungal balls of hyphae of Aspergillus fumigatus.

Aspergillus

Fig 4: Grocott’s methenamine silver (GMS) stained tissue sections showing Aspergillus fumigatus in lung tissue, note conidial heads forming in an alveolus.

Fig 6: Aspergillus terreus on Czapek dox agar showing typical suede-like cinnamon-buff to sand brown colonies. Reverse yellow to deep dirty brown.

Treatment of Invasive Aspergillosis

IDSA Guidelineswww.idsociety.orgCID 2008:46 (Feb)

Primary agent: VoriconazoleAlternative agents: L-Amphotericin ,

Posaconazole, Micafungin, Caspofungin, Itraconazole

Fig 8: Antifungal susceptibility disk test showing the in vitro activity of Voriconazole against Aspergillus fumigatus with Candida krusei as a control.