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Î In lung transplant recipients not on anti-mold prophylaxis, the
IDSA suggests pre-emptive therapy with an anti-mold antifungal for
asymptomatic patients with Aspergillus colonization of the airways
within 6 months of lung transplantation or within 3 months of receiving
immunosuppression augmentation for rejection (W-M).
Î Six months after lung transplantation and in the absence of recent
immunosuppression augmentation for rejection, it may be prudent to
withhold antifungal therapy for Aspergillus airway colonization (i.e.,
Aspergillus respiratory cultures in the absence of clinical features that
suggest disease, such as compatible symptoms, or bronchoscopic,
histopathologic and/or radiographic findings) (W-L).
Chronic and Saprophytic Syndromes
Î The IDSA suggests an individualized approach that takes into
consideration the rapidity and severity of infection and local
epidemiology (W-M).
Chronic Cavitary Pulmonary Aspergillosis (CCPA)
Î The diagnosis of CCPA requires (S-M):
• 3 months of chronic pulmonary symptoms or chronic illness or progressive
radiographic abnormalities, with cavitation, pleural thickening, peri-cavitary
infiltrates and sometimes a fungal ball
• Aspergillus IgG antibody elevated or other microbiological data (The Aspergillus
IgG antibody test is the most sensitive microbiological test.)
• No or minimal immunocompromise, usually with one or more underlying
pulmonary disorders.
Note: Sputum Aspergillus PCR testing is more sensitive than culture (W-M).
Î Patients with CCPA without pulmonary symptoms, weight loss or
significant fatigue, and those without major impairment of pulmonary
function or gradual loss of pulmonary function may be observed
without antifungal therapy and followed every 3–6 months (W-L).
Î Patients with CCPA and either pulmonary or general symptoms or
progressive loss of lung function or radiographic progression should
be treated with a minimum of 6 months of antifungal therapy (S-L).
Î Oral itraconazole and voriconazole are the preferred oral antifungal
agents (S-H). Posaconazole is a useful third-line agent for those with
adverse events or clinical failure (S-M).
Î Hemoptysis may be managed with oral tranexamic acid (W-L),
bronchial artery embolization (S-M) or antifungal therapy to prevent
recurrence (S-L).
• Patients failing these measures may require surgical resection (W-M).
