Aspergillosis of the lungs is a fungal disease. Aspergillosis

Pulmonary aspergillosis is a disease caused by various types of fungi of the genus Aspergillus. This is one of the most common fungal infections of the lungs.

Pathogenic fungi this kind capable of causing lung diseases that differ in clinical picture and prognosis, which occur in different patient populations and require different approaches to diagnosis and treatment. The most common among them are invasive, chronic necrotizing pulmonary aspergillosis, allergic bronchopulmonary aspergillosis, and aspergilloma.

Predisposing factors

Aspergillosis is a fungal disease, one of the most common mycoses affecting the lungs.

Aspergillus is widely distributed in nature. They have great biochemical activity, form various enzymes, some of them are able to produce endotoxins and have an allergenic effect on the body. They can be found in:

• soil,
• grain,
• flour
• hay,
• house dust.

Infection occurs by inhalation of air containing spores of the fungus. Other routes of infection (food, contact) are also possible, but are of lesser importance. There were no cases of infection from a sick person.

It should be noted that not everyone gets aspergillosis. The following factors contribute to its development:

1. HIV infection and other immunodeficiencies.
2. Long-term use of cytostatics or corticosteroids.
3. Malignant neoplastic process, including acute leukemia.
4. Tuberculosis.
5. chronic diseases bronchopulmonary system(, lung abscess).
6. Diabetes.
7. Chronic granulomatous disease.
8. Alcoholism and drug addiction.
9. Severe general diseases.

It is also possible nosocomial infection of patients in intensive care and intensive care without any risk factors.

Invasive aspergillosis

The length of the incubation period for invasive aspergillosis has not been determined. Often clinic this disease preceded by aspergillus colonization respiratory tract.

Symptoms

The main signs of the disease are:

• fever unclear etiology lasting more than 4 days and refractory to antibiotics;
• unproductive;
• hemoptysis;
• dyspnea;
• pain in chest.

These symptoms can have varying degrees of severity, and the latter does not determine the severity of the condition. So, in people with a pronounced decrease in immunity, the manifestations of the disease may be absent even with the development of an infection that poses a threat to life.

Diagnostics

The following methods are used to diagnose invasive aspergillosis:

1. or computed tomography (allows you to identify characteristic foci in the form of a halo, crescent).
2. Determination of a specific antigen in blood serum.
3. Microscopy and culture of sputum.
4. with a biopsy.

Radiological symptoms are not pathognomonic, but in combination with other signs of the disease and microbiological confirmation, they help to make the correct diagnosis.

• The halo symptom occurs in the first week of the disease and is a zone of hemorrhage around the lesion. It is a characteristic feature of aspergillosis, but also occurs in other mycotic lesions of the lungs.
• The symptom of the crescent indicates the formation of a cavity in lung tissue, it comes to light on the third week of an illness.

The method for determining specific antibodies in the blood in the category of patients with immunodeficiency is not used, since in such persons the process of their formation is disrupted.

Treatment

To eliminate the cause of aspergillosis (pathogenic fungus), the patient will be prescribed antifungal drugs.

Complex medical measures for invasive aspergillosis includes:

1. Reducing the severity or eliminating risk factors (treatment of the underlying disease, correction of neutropenia, dose reduction of cytostatics or corticosteroids).
2. Prescribing antifungal drugs.
3. Surgical intervention.

Identification of signs of the disease is an indication for the immediate initiation of treatment. In addition, antifungal therapy is prescribed for high risk disease progression but no laboratory confirmation.

The causative agents of aspergillosis are sensitive to:

• voriconazole
• posaconazole
• amphotericin B,
• itraconazole.

But they are resistant to fluconazole and ketoconazole.

Voriconazole is the drug of choice for the treatment of invasive aspergillosis. However, from an economic point of view, amphotericin B, which is less effective and highly toxic, is often used for this purpose.

The average duration of antifungal therapy for aspergillosis is about 3 months. Moreover, in individuals with persistent immunosuppression, longer treatment is required.

Surgical treatment is carried out at a high risk of pulmonary hemorrhage and consists in resection of the affected segment. It is usually carried out after the patient's condition has stabilized against the background of antifungal therapy. Removal of individual affected lung segments avoids recurrence of the disease.

Without treatment invasive aspergillosis almost always has an unfavorable outcome. Adequate and timely therapy can reduce the mortality rate to 30-50%.

Chronic necrotizing aspergillosis

This is a fairly rare pathology, which accounts for about 5% of all cases of aspergillosis.

Most of the disease has a chronic course with periodic exacerbations and progressive impairment of lung function due to the development of fibrosis.

These patients are concerned about:

• chronic cough with sputum;
• hemoptysis varying degrees expressiveness;
• an increase in body temperature to subfebrile figures;
• weakness and decreased performance;
• weight loss.

Over time, the pathological process spreads to the surrounding tissues. In this case, the ribs, spine are affected, and pulmonary bleeding may develop.

The diagnosis is made on the basis of:

• clinical signs;
• data x-ray examination or computed tomography (multiple cavities with a zone of inflammation around, located mainly in the upper parts of the lung);
• detection of mycelium of a pathogenic fungus in sputum or biopsy material;
• specific antigen in the blood.

Treatment for chronic necrotizing aspergillosis is long-term with the obligatory use of antifungal drugs. Surgical treatment is used for increased risk bleeding or in the presence of a single focus, refractory to treatment.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis is caused by a hypersensitivity reaction in a patient with colonization of the respiratory tract by a fungus of the genus Aspergillus.

Contributes to the onset of the disease congenital predisposition, often it is detected in patients with cystic fibrosis or. This pathology has a chronic course with periodic exacerbations in the form of bronchial obstruction syndrome or education eosinophilic infiltrates in lung tissue.

The most common manifestations of allergic bronchopulmonary aspergillosis are:

• cough with sputum containing mucous plugs;
• bouts of shortness of breath;
• pain in the chest;
• "Flying" infiltrates in the lungs or bronchiectasis on the x-ray;
• mycelium of a pathogenic fungus in sputum;
• eosinophilia in the blood during an exacerbation;
• increase in total IgE;
• detection specific immunoglobulins in the blood during an exacerbation.

Corticosteroids are the mainstay of treatment for this pathology. They are used to achieve remission, the duration of such treatment is 3-6 months.

During remission specific treatment not carried out. With a relapse, the activity of the process is reduced by hormonal drugs, after which a long-term intake of itraconazole (2-4 months) is prescribed.

Aspergilloma

Aspergilloma is a pathological process in which Aspergillus mycelium grows in lung cavities that have previously formed (for example, with tuberculosis or lung abscess).

At first, the disease is asymptomatic. Over time, patients begin to worry about coughing with hemoptysis, fever. With secondary bacterial infection of the cavity affected by fungi, signs of an acute inflammatory process may occur.

Approximately 10% of aspergilloma symptoms resolve on their own without treatment. However, in some patients, its course is complicated:

• bleeding;
• invasive aspergillosis;
• chronic necrotizing aspergillosis;
• germination of the pleura and the development of its specific inflammation.

Treatment of aspergilloma is carried out at a high risk of complications. Its main method is surgical intervention in order to remove the pathological focus. At the same time, to reduce the likelihood of infection of surrounding tissues, antifungal drugs are prescribed before and after the operation.

If the operation is contraindicated for the patient with general serious condition or expressed respiratory failure, then alternative method treatment may be long-term use of itraconazole and washing the cavity with amphotericin B.

Conclusion

Aspergillosis is one of the diseases that have a fairly serious prognosis. When it pulmonary forms mortality reaches 35%, and in people with HIV infection - 50%. And clinical variant disease and the severity of its course are determined not by the characteristics of the pathogen, but by the state immune system.

In the program “About the most important thing” about aspergillosis (watch from 19:20 min.):

Aspergillosis is common name diseases caused by fungi of the genus Aspergillus. Although the disease affects various bodies The most common diagnosis is pulmonary aspergillosis. Clinical picture so diverse that it requires a special approach in treatment. Timely diagnosis warns serious complications and lethal outcome. Mortality from bronchopulmonary aspergillosis is 30%. Moreover, every second HIV-infected person dies from this pathology.

The source of a fungal infection can be not only soil and air, but also books, houseplants, feather pillows, a humidifier and an inhaler.

The pathogen enters the human body by airborne droplets. There is also a possibility of infection through open wound and with food. First of all, the fungus affects the lungs, and then spreads to the lymphatic system and pleura.

The risk group for invasion includes agricultural workers, flour millers, workers in textile and paper processing plants, as well as people whose occupation is associated with breeding pigeons.

Developing in the lungs, aspergillus gradually form entire colonies. Their active vital activity can proceed on the surface of tissues, in the depths of the bronchi, lungs and even arteries. In the latter case, granulomas are formed that provoke inflammation. This entails bleeding, tissue necrosis and pneumothorax (accumulation of gases and air in the pleural cavity).

It is difficult to establish the exact limits of the incubation period, because the rate of development of the disease largely depends on individual characteristics, immunity of the patient, concomitant diseases and age. Also, factors that affect the development of pathology are:

• chronic diseases of the ENT organs (especially otitis media) and the respiratory system;
• prolonged use of antibiotics, cytotoxic agents and corticosteroids;
• bone marrow transplantation and other organ transplants;
• prolonged radiation therapy;
• low levels of neutrophils in the blood.

A person can be a carrier of aspergillosis for a long time without being aware of it. With a decrease in immunity, aspergillus colonization develops at a significant pace.

The reaction of tissues to a fungal infection is diverse: serous or purulent. Sometimes even tuberculoid granulomas are formed.

Symptoms of pulmonary aspergillosis

The most common symptom of pulmonary aspergillosis in humans is wet cough with sputum gray color. Occasionally, greenish clots may be observed in it.

Common symptoms of this disease include:

• an unpleasant aftertaste of mold in the oral cavity;
• decreased ability to work and general malaise;
• hyperthermia and chills;
• chest pain and shortness of breath;
• poor appetite;
• frequent insomnia.

Types of fungus

Exist different types pulmonary aspergillosis. They are presented in the following table.

View	Features of the disease	Symptoms
Exogenous alveolitis	Occurs when organic dust is inhaled, resulting in damage to the alveoli and bronchioles.	Hyperthermia, coughing up blood and/or mucus, deterioration in bronchial asthma.
Invasive aspergillosis	It can have three forms: chronic, acute and subacute.	Dry cough, fever, shortness of breath, signs of pulmonary embolism.
intracavernous aspergillosis	Formed in the cavities of the lungs due to tuberculosis, emphysema and sarcoidosis.	Cough attacks with blood, rapid fatigue, weakness, weight loss, shortness of breath with wheezing.
	Often seen in patients bronchial asthma and cystic fibrosis.	High body temperature, migraine, anorexia, cough with dirty green or brown sputum, sometimes with blood.
Disseminated aspergillosis	Development occurs torpidly (insensibly, sluggishly) with mild exacerbations.	Symptoms of the disease proceed according to the type of chronic pneumonia.
non-invasive form	In immunocompetent individuals, it occurs in the form of colonization, carriage, or aspergilloma.	None.

Depending on the location of the fungal infection, local (isolated) and generalized aspergillosis. In the first case, the fungus spreads only to the lungs, and in the second case, it involves the skin, liver, spleen, brain and skeletal system in the pathological process.

Depending on the scale, it is customary to distinguish light, medium and severe degree aspergillosis. Also, the pathology can occur in acute and chronic form.

Diagnostics

First of all, the specialist collects anamnesis data. He finds out whether a person is at risk of infection with this disease, and in what conditions he lives. It is important for the doctor to know what medications the patient has taken recently. He is also interested in what comorbidities there are, and checks the condition of his nasopharynx.

If the patient complains of signs characteristic of aspergillosis, and the history data confirm this, the doctor directs for passage. These include:

Clinical picture

As part of federal program, when submitting an application, each resident of the Russian Federation and the CIS can receive an INTOXIC package WITH DISCOUNT!

• Sputum analysis. Indicates the presence of aspergillus.
• Biochemical and general analysis blood. Confirms allergic processes or inflammation.
• PCR method. Allows you to find out the presence of aspergillus waste products or their nucleic acids.
• Serological tests. Determine the presence in the body of antibodies to aspergillus antigens.
• Particle biopsy lung tissue and histological examination.
• Bronchoscopy. Using this method, it is possible to obtain a wash for microbiological and cultural examination.
• Respiratory x-ray. Shows pathological changes in the lungs, so-called. halo symptom (perifocal swelling and hemorrhages) and "sickle symptom" (necrosis in the thickness of the inflammation).
• CT and MRI. Aspergillosis of the lung on CT and MRI shows multiple formations of aspergillus.

Differential diagnosis is needed for suspected candidiasis, cystic fibrosis, sarcoidosis, pulmonary tuberculosis, malignant and benign formations in the respiratory organs.

Features of the treatment of aspergillosis

First of all, when confirming the diagnosis, antifungal therapy is prescribed. If the patient suffers from an advanced form of aspergillosis, then it will be combined: surgical intervention with the use of medications. All clinical guidelines for the treatment of pulmonary aspergillosis are given below.

With the help of drugs

During the treatment of pulmonary aspergillosis, it is prescribed whole complex drugs. But the main component of therapy is antifungals. Most often, the doctor prescribes such medicines:

• Amphotericin B. The drug is administered intravenously, and the dosage is calculated taking into account body weight (250 IU per kg). The course of treatment ranges from 4 to 8 weeks.
• Mycoheptin. The medicine is taken orally (0.4-0.6 grams) twice a day. The duration of therapy is 2 weeks.
• Amphoglucamine. It is prescribed for adults and children from 14 years of age. The initial dosage is 20 thousand IU twice a day, with insufficient effectiveness - 50 thousand IU twice a day. Treatment lasts from 3 to 4 weeks.

Voriconazole is also the drug of choice for the treatment of pulmonary aspergillosis. There are 2 ways to take the drug - oral and intravenous.

At internal application the first 24 hours take 400 mg twice a day if the patient's weight exceeds 40 kg. When the weight is less than 40 kg, drink 200 mg. After 24 hours, use 100 mg (less than 40 kg) or 200 mg (more than 40 mg) 2 times a day. 6 mg per kg of body weight is administered intravenously for the first 24 hours, and then 4 mg per kg of body weight per day.

In addition to antifungal drugs, the doctor prescribes the following drugs:

• Corticosteroids, which suppress allergies. They are also used to prevent asthma or cystic fibrosis.
• Multivitamin complexes. Since a person's immune system is very weakened, he needs minerals and vitamins to fight aspergillus.

Each drug has a number of contraindications. Concerning self-administration strictly prohibited.

During drug therapy, the patient is periodically checked using computed tomography. The main specialists who monitor the patient are an ENT doctor, a pulmonologist and a therapist.

Surgery

In advanced cases drug treatment unable to cope with the disease, therefore, surgical intervention is prescribed. It is effective when there is profuse hemoptysis, but the functional abilities of the organ are preserved.

If there is a risk of pulmonary bleeding, then the parts of the organ affected by the fungal infection are resected. When removing sections, they are scraped in advance.

The bleeding is stopped in the following way:

1. A catheter is inserted into the vessel leading to the aspergilloma.
2. Through it, a blocking material is injected into the cavity of the artery.
3. Thus, the bleeding stops.

It can also be stopped by temporarily ligating the bronchial artery.

Prognosis and complications

Recovery depends on the severity comorbidities and human immunity. Death is recorded in 25-30% of cases. Moreover, every second HIV-infected person dies of aspergillosis..

If the disease has affected only the mucous membrane or ENT organs, then the prognosis is more favorable. The earlier the diagnosis is made, the more chances to overcome this disease. Special attention deserves, which can be found in our separate material.

Clinical picture

Chief Physician of the Moscow City Hospital No. 62. Anatoly Nakhimovich Makhson
Medical practice: more than 40 years.

Unfortunately, in Russia and the CIS countries, pharmacy corporations sell expensive drugs that only relieve symptoms, thereby putting people on one drug or another. That is why in these countries there is such a high percentage of infections and so many people suffer from "non-working" drugs.

The main complications of pulmonary aspergillosis include:

• Massive bleeding that is very difficult to stop. If this fails, the patient may die as a result of respiratory failure or blood loss.
• Spread of infection to other organs. Aspergillosis can migrate through bloodstream throughout the body. If you do not start timely therapy of the invasive form, then this will lead to death.

Prevention

To reduce the likelihood of developing the disease to zero, it is necessary to follow the rules of prevention:

• timely treat diseases of the respiratory tract and ENT organs;
• regularly undergo a medical examination;
• exclude contact with mold;
• comply with all safety rules at work;
• improve ventilation in damp rooms;
• do not come into contact with an infected person;
• improve sanitary and hygienic conditions at agricultural factories.

Better not to use folk remedies but only with the approval of the attending physician. They cannot eliminate fungal infection, but increase the body's defenses.

Why fungal diseases are dangerous: Video

Have you even read something about drugs designed to defeat the infection? And this is not surprising, because worms are deadly for humans - they are able to multiply very quickly and live long, and the diseases they cause are difficult, with frequent relapses.

Bad mood, lack of appetite, insomnia, dysfunction of the immune system, intestinal dysbacteriosis and abdominal pain... Surely you know these symptoms firsthand.

No related posts

Stefan Schwartz and Markus Ruhnke

Fragment of chapter 24 of the monograph "Aspergillus fumigatus and Aspergillosis", Ed by J.P. Lungi and W.J. Stenbach, 2009, ASM Press, Washington.

Introduction. Fungi of the genus Aspergillus are the most commonly isolated pathogen in patients with fungal sinusitis. Aspergillosis paranasal sinuses The nose is almost always the result of inhalation of spores from the air. Sometimes the disease can occur as a complication after invasive procedures such as trassphenoidal surgery. In addition, aspergillosis of the maxillary sinuses has been described in combination with dental treatment, such as endodontic therapy. These patients move filling material from root canal into the maxillary sinuses, which happens quite often. Interestingly, experimental data show that zinc, potentially released from the filling material, promotes the growth of Aspergillus fungi.

Aspergillus rhinosinusitis was first described over a century ago, but proposals for a comprehensive classification of fungal sinusitis that take into account clinical, radiographic, and histological characteristics were not published until 1997. The primary picture that distinguishes the various forms of fungal sinusitis is the absence (non-invasive sinusitis) or presence (invasive sinusitis) of invasion by fungal elements and tissue necrosis. Aspergillus sinus infections can be divided into five major subtypes. Invasive forms are acute sinusitis(rapid, fulminant), chronic sinusitis (sluggish) and chronic granulomatous sinusitis; while non-invasive forms are fungal lump (aspergilloma) and allergic fungal sinusitis (Table 1).

Despite this classification of Aspergillus sinusitis into at least five subtypes, epidemiological data on the frequency and distribution of these names are limited. One of the largest published series analyzed data from 86 patients with histologically proven fungal infection of the sinuses (Driemel et al ., 2007). Invasive fungal sinusitis was observed in 22 patients (11 men) with a mean age of 57 years (range 22 to 84 years). Of these, 41% had immunodeficiency states, including diabetes(three patients), various malignancies (five patients), and bacterial endocarditis(one patient). Mushroom lump was identified in 60 patients (of which 26 men) who had a mean age of 54 years (range 22 to 84 years). Immunodeficiency states were observed in only 15% (9/60) of these patients, including diabetes mellitus (two patients), solid tumors with combined chemotherapy and radiotherapy (four patients). Allergic fungal sinusitis was described in only four patients, who had a lower mean age of 43 years (17 to 63 years) compared to all other patients.

Interestingly, other reports of acute invasive fungal sinusitis have found this form exclusively in severe immunodeficiency conditions, especially in patients with malignant hemoblastoses such as acute leukemia or conditions after bone marrow transplantation. Finally, there are allergic fungal sinusitis, which will not be discussed in this chapter.

Non-invasive Aspergillus sinusitis.

Acute rhinosinusitis is most commonly caused by bacterial or viral pathogens. In chronic and recurrent forms of non-invasive rhinosinusitis, fungi can also be the causative pathogen. The symptoms presented are usually non-specific and may lead to a delay in diagnosis. However, in isolated sphenoid sinuses, approximately 20% of diseases can cause fungal clumps, with Aspergillus as the most common pathogen. Up to 60% of cases of processes with the formation of fungal lumps, the culture of fungi may not be determined, and only a histological examination can be the basis for the diagnosis.

Classification.

Non-invasive forms of Aspergillus sinusitis almost always occur in immunocompetent patients, which can be generally divided into allergic sinusitis and fungal sinus lumps, or mycetomas. However, other publications present other manifestations. A prospective study from India described three types of sinus aspergillosis, which were termed chronic invasive, non-invasive (mushroom ball) and non-invasive destructive. for non-invasive destructive and chronic invasive diseases, additional chemotherapy was performed.

Diagnostics.

Most patients with allergic fungal sinusitis suffer from chronic sinusitis, nasal polyps, asthma, and atopy. Signs of allergic fungal sinusitis are the presence of "allergic mucin" in the sinuses, which is often multi-layered and consists of cellular debris, eosinophils, Charcot-Leiden crystals, and only a small amount of fungal elements. The second non-invasive form of Aspergillus sinusitis, sinus mycetoma, is preferably referred to as fungus or aspergilloma. A Turkish study performed between 1993 and 1997 described 27 cases of fungal sinusitis. Of these, 22 were non-invasive forms and 5 were invasive. Eleven patients were diagnosed with mycetoma, nine had allergic fungal sinusitis, three had acute fulminant (fulminant) sinusitis, and two had chronic flaccid sinusitis, although two patients were not included in any of the four subgroups of sinusitis. In all cases, the mycetoma fungal pathogen was identified as Aspergillus.

Patients with sinus aspergilloma usually report facial pain, nasal obstruction, nasal discharge, and bad breath (cacosmia). The x-ray usually shows a unilateral lesion of the maxillary sinus, but several sinuses may be involved. In most patients with sinus aspergilloma, computed tomography (CT) detects heterogeneous density in the affected sinuses, including microcalcifications or metallic density materials. These radiological changes are determined by the deposition of calcium salts and the formation of fungal calculi. Detection of fungal mycelium in a fungal bolus has over 90% sensitivity in making a diagnosis, while culture has much less sensitivity (less than 30%) in this subtype of fungal sinusitis. Thus, due to the low sensitivity of mycological culture, histology should always be used to make a diagnosis of fungal sinusitis. What factors, excluding allergies, contribute to the formation of Aspergillus sinusitis in immunocompetent patients is largely unknown. Recent data obtained from a study of immunocompetent rabbits have shown that impaired aeration of the paranasal sinuses is a factor in the entry of fungal spores and a major factor leading to the development of fungal sinusitis.

Despite the absence of tissue invasion by fungi in allergic fungal sinusitis caused by fungi of the genus Aspergillus and aspergilloma of the paranasal sinuses, these subtypes of fungal sinusitis may develop the inclusion of neighboring structures in the inflammatory process, which sometimes requires surgical treatment. Allergic Aspergillus sinusitis or sinus aspergilloma may be accompanied by orbital and even intracranial spread causing proptosis, diplopia, visual loss and paralysis cranial nerve. In some individuals with allergic fungal sinusitis or sinus aspergilloma, bone erosion may be found, which is usually due to chronic inflammation and expansion of the fungal mass, rather than due to tissue invasion of the fungi. Any sinuses may be affected, but the lamina papiracea lesion predominates.

The series described by Liu et al described 21 immunocompetent patients with a mean age of 25 years (9 to 46 years) and a male/female ratio of 3.75:1. All patients had a history of chronic sinusitis with x-ray evidence of involvement of multiple sinuses. Fifteen had nasal polyps, eight had CT bone erosions, eight had intracranial extension, and six had a lamina papiracea process.

Due to the spread of the inflammatory process with bone erosion in a subgroup of immunocompetent patients with non-invasive fungal sinusitis, some authors coined the term "destructive non-invasive sinus aspergillosis" and "erosive fungal sinusitis", defining this disease as an intermediate form between aspergilloma, allergic and chronic fungal sinusitis, however, these terms do not define the underlying causes of the disease.

Table 1. Clinical and pathological subtypes of Aspergillus sinusitis.

Subtype of sinusitis	Clinical	Immunosuppression	Histopathology
non-invasive
Allergic	Chronic sinusitis, polyps, often atopy		"Allergic mucin" with eosinophils, Charcot-Leyden crystals, but little mycelium; no tissue invasion	Debridement, sinus aeration, steroids
Mushroom lump (aspergilloma or mycetoma)	Symptoms of chronic sinusitis, nasal polyps, sinus calcification, sometimes atopy		Mushroom lump containing mycelium may contain calculi, but there is no tissue invasion.	debridiment, sinus aeration
invasive
Acute (lightning fast)	Fever, pain, nasal discharge or congestion, epistasis, periorbital edema, rapid onset		Invasion of the mucosa, submucosa, bones and vessels with severe tissue necrosis
Chronic	Symptoms of chronic sinusitis, often misdiagnosed as pseudotumorous inflammation associated with orbital apex syndrome		Scattered chronic inflammatory infarction with vascular invasion of fungal elements, dense accumulation of mycelium	Debridement/resection if possible early start systemic antifungal therapy (preferably voriconazole)
Granulomatous	Chronic slowly progressive sinusitis associated with proptosis		Severe granulomatous inflammation without tissue necrosis, but often extending beyond the sinuses	Debridement/resection if possible, administration of systemic antifungal therapy

Therapy.

Treatment of non-invasive Aspergillus sinusitis consists of surgical removal of the allergic mucin or fungal bolus and aeration of the sinuses under endoscopic observation. Using these approaches, most patients with Aspergillus sinus disease achieve long-term remission and do not require additional treatment. However, patients with allergic forms of Aspergillus sinusitis often relapse this disease. Washing with isotonic saline, topical or systemic corticosteroid therapy, as well as immunocorrective therapy can prevent mucoid occlusion and suppress the inflammatory response in these patients.

A limited number of infections do not require systemic antifungal therapy, and improvement has not been proven in patients with non-invasive forms of Aspergillus sinusitis. However, corticosteroid therapy may reduce local inflammation, which is associated with a reduction in the number of relapses in patients with allergic fungal sinusitis. In the observation of 21 patients with allergic fungal sinusitis, all received transnasal or transmaxillary endoscopy performed for debridement or irrigation, six patients underwent orbital decompression and 3 - bifrontal craniotomy to remove the intracranial extradural process. None of the patients developed cerebrospinal fluid secretion. In the postoperative period, one patient was treated with amphotericin B, and the other 20 received a short course of corticosteroids. Karci et al. reported a series of 27 patients with fungal sinusitis, including 22 patients with non-invasive Aspergillus sinusitis, all treated with endoscopic sinus surgery. Infection recurred in 2 with allergic fungal sinusitis and in another patient with chronic invasive sinusitis within 20 months.

Acute (fulminant) invasive Aspergillus sinusitis.

Fulminant or acute invasive Aspergillus sinusitis was first described as independent disease in 1980. This aggressive form of Aspergillus sinusitis is characterized by sudden onset with rapid progression and a tendency to destructive invasion of adjacent structures. This process develops exclusively in patients with severe immunodeficiency, including patients with profound neutropenia (ie, acute leukemia, aplastic anemia, and conditions after chemotherapy), patients with AIDS, or patients after bone marrow transplantation. Of note, acute invasive aspergillus sinusitis is less common than invasive pulmonary aspergillosis, with a sinus incidence of only 5% compared with a pulmonary incidence of over 56% in immunocompromised patients with invasive aspergillosis. However, invasive pulmonary aspergillosis and sinusitis may coexist in selected patients.

The reported incidence of invasive fungal sinusitis in bone marrow transplant patients varies between 1.7% and 2.6% at the two institutions between 1983 and 1993. Kennedy et al. reported that survival in invasive fungal sinusitis did not depend on the age of the patients, the number of leukocytes at the onset of the disease, the dose and type of antifungal therapy, and the degree of surgical resection. Their study concluded that only intracranial and/or orbital involvement is a poor prognostic sign. A significant proportion of patients (50%) do not recover from invasive fungal sinusitis despite recovery of neutrophils after transplantation. In this series, 61% of patients who died from infection had prior major surgery versus 55% of those who cleared from infection. In contrast, Gillespie et . al. concluded that complex surgical resection with negative margins and recovery from neutropenia appears to be a critical factor for the survival of patients with invasive fungal sinusitis.

Microbiology and pathology.

Aspergillus flavus was isolated from most patients with acute invasive fungal sinusitis. Kennedy et al. reported that a. flavus (n=9), Aspergillus fumigatus (n=3), and other unspecified Aspergillus species (n=2) were isolated from 26 bone marrow transplant patients with invasive fungal sinusitis. Drakos et al. described 11 patients with invasive fungal sinusitis that occurred among 423 bone marrow transplant patients and isolated A. flavus in 7 patients and Aspergillus qadrilineatus in 1 patient. However, most data on invasive fungal sinusitis were published more than 10 years ago and in this regard, the current epidemiology of A . flavus remains largely unknown. It is not clear why A . flavus, not A. fumigatus is the predominant mold found in acute fungal sinusitis. Curiously, the spores of A. flavus somewhat larger than A. fumigatus (8 vs. 3.5 μm), which may contribute to their retention in the upper respiratory tract. In acute invasive sinusitis, histology usually shows fungal invasion of the mucosa, submucosa, bone, and vessels with extensive tissue necrosis. Tissue invasion by neutrophils is usually also present, but may be less pronounced or absent in patients with neutropenia. Recently, the important role of neutrophils has been established as defense mechanism against aspergillosis of the paranasal sinuses, which was determined in experimental mouse models in which neutrophils were depleted by antigranulocytic monoclonal antibodies. The presence of neutrophils was the basis for the protection of the paranasal sinuses against acute Aspergillus infection and in the clearance of the identified mycelial masses.

Diagnostics.

Persistent fungal invasion of adjacent structures is a frequent and threatening complication that can lead to orbital cellulitis, retinitis, palatal destruction, and brain abscess formation. Symptoms that can help make a quick diagnosis in a risk group include fever, abdominal pain facial area, nasal obstruction or purulent discharge, epitaxis and periorbital edema. CT or MRI allows early detection of inflammatory soft tissue edema, bone destruction or invasion of adjacent structures and allows for subsequent diagnostic measures and surgical treatment. A definite diagnosis of acute invasive Aspergillus sinusitis requires tissue biopsy, but this results in an undesirable risk of bleeding in patients with thrombocytopenia and may require general anesthesia. Rigid nasal endoscopy may be recommended in patients at risk with specific symptoms and may reveal mucosal discoloration, crusting, ulceration, and may allow targeted biopsy. If a biopsy is possible, routine preparation of specimens is laborious and delays diagnosis. In a recent study, frozen biopsies were compared with long-term biopsies obtained from 20 patients with invasive fungal sinusitis. Evaluation of frozen biopsies yielded a sensitivity of 84% and a specificity of 100% for the presence of invasive fungal infection. In addition, analysis of frozen biopsies correctly separated aspergillosis cases from non-aspergillosis cases. Using this technique, more fast diagnostics may contribute to a more rapid initiation of appropriate therapy and will determine the amount of necessary surgical treatment. Nasal swab culture has acceptable sensitivity, but rather low specificity for the suspicion of invasive Aspergillus sinusitis. Of note, cultures obtained from nasal washes from healthy volunteers often produce fungal growth (over 90%), including Aspergillus species.

Promising diagnostic approaches are the identification of fungi from fungal clumps obtained from maxillary sinuses using PCR with universal fungal primers on 28S rDNA and amplification identification by hydrolysis with species-specific probes along with sequencing include fungi of the genus Aspergillus such as A. fumigatus, A. flavus, A. Niger, A. terreus and A. glaucus. In one study, 112 specimens were obtained from patients with histologically proven fungal infections. Eighty-one specimens from the maxillary sinuses were embedded in paraffin and 31 were fresh biopsies. Fungal DNA was found in all fresh biopsies and only in 71 (87.7%) paraffin-embedded tissue samples. Sequencing analysis was the most sensitive technique, as positive results were obtained in 28 (90.3%) fresh samples compared to 24 (77.4%) samples using the hybridization technique and only 16 (51.6%) samples using the culture method. .

Treatment.

When symptoms and manifestations of invasive Aspergillus sinusitis are present, surgical intervention and active removal of dead tissue that can support fungal growth should be performed to obtain material for histological examination. Thereafter, broad-spectrum antifungal therapy should be initiated immediately, even before histological evidence of tissue invasion is obtained. Complex resection, including major resection, improves survival and should be attempted.

With regard to antifungal therapy, amphotericin B has been the standard of care in the past and can be used as an alternative drug when resources are scarce. In contrast, some studies have successfully used itraconazole either alone or in combination with amphotericin B. However, the response to amphoterin B is limited because the result complete cure or the rate of stable remission is only about 30%. Using liposomal amphotericin B as a second-line therapy in seven patients with invasive sinonasal aspergillosis who failed conventional amphotericin B therapy, Weber and Lopez-Berestein (1987) reported a cure for this disease in five patients. In contrast, a mortality rate of at least 50% has been re-described. Newer drugs such as caspofungin, micafungin or voriconazole are described as effective treatment acute invasive Aspergillus sinusitis in immunocompromised patients as monotherapy or in combination (second-line drug). These observations have shown that the effect of the latest drugs as second-line therapy in some cases is feasible even without surgical intervention. In general, since data from randomized prospective studies are not available for these rare indications, an antifungal therapy strategy for acute invasive Aspergillus sinusitis should be consistent with a strategy for the treatment of niva- sive pulmonary aspergillosis that supports voriconazole as first-line therapy.

Chronic nivazivny Aspergillus sinusitis.

Patients with chronic invasive Aspergillus sinusitis suffer from comorbid conditions that cause low levels of immunosuppression (eg, poorly controlled diabetes mellitus or long-term treatment with corticosteroids). Chronic invasive fungal sinusitis may differ from the other two forms of invasive fungal sinusitis in its chronic course, dense mycelial accumulation with mycetoma formation, and association with orbital apex syndrome, diabetes mellitus, and corticosteroid treatment. Orbital apex syndrome is characterized by decreased vision and eye movement due to orbital mass. This condition may be misdiagnosed as an inflammatory pseudotumor and corticosteroid therapy may be initiated prior to appropriate eye examination and biopsy. The optimal treatment strategy has not yet been determined, but due to the poor prognosis, chronic invasive Aspergillus sinusitis should be treated in the same way as acute invasive Aspergillus sinusitis, that is, with broad-spectrum antifungals.

Chronic granulomatous invasive Aspergillus sinusitis.

Chronic granulomatous sinusitis is a syndrome of slowly progressive sinusitis associated with proptosis, also referred to as flaccid fungal sinusitis or primary paranasal granuloma. In this condition, histological preparations show pronounced granulomatous inflammation. Primary paranasal Aspergillus granuloma is, by one definition, a slowly progressive chronic sinus infection extending beyond the sinuses. This was observed only in patients from Sudan, India, and one case was described in Saudi Arabia and in the United States. Microscopically, it differs from chronic invasive fungal infection: there are pseudotubercles containing giant cells, histiocytes, lymphocytes, plasma cells, newly formed capillaries, eosinophils, and elements of fungi of the genus Aspergillus. Dawlatly et al suggested that, in view of the geographic similarities between northern Sudan and Saudi Arabia, some of the granulomatous inflammatory conditions occurring in Saudi Arabia, in which the etiologic agent has not been identified, could be included in this category.

Descriptions not derived from Africa or the Indian subcontinent (eg, from the United States) suggest that primary paranasal Aspergillus granuloma affects almost exclusively African Americans. Whether there is a climate influence and/or genetic predisposition is still unknown. Patients are immunocompetent and become infected almost exclusively with A. flavus. Interestingly, they often have bone erosion and tissue destruction that occurs as a result of mass spread rather than vascular invasion. Most affected individuals have unilateral proptosis. Clear regression usually occurs after surgery to restore adequate aeration to the sinuses. However, the recurrence rate is very high (approximately 80%) and there are suggestions that the use of antimycotics may suggest improvement, but the optimal therapy for such conditions remains unclear.

Aspergillosis of the lungs is a fungal disease caused by molds aspergillus. This is an extremely dangerous disease that requires immediate diagnosis and treatment. Delay can cost the patient his life.

The main cause of pulmonary aspergillosis is the entry of fungi into the body with inhaled air. The spores settle on the walls of the bronchi and lungs and, after the incubation period, begin to affect the surrounding tissues. Abscesses and fistulas are formed on the affected membranes, releasing thick pus. But not all infected people develop the disease. Certain factors are necessary for the activation of microorganisms.

The causative agent of the disease is the fungus Aspergillus under a microscope

Decreased immunity

Persons with weakened body defenses are most susceptible to pathology. Provoking factors are AIDS and other immunodeficiency states, diabetes mellitus, alcoholism, drug addiction. Immunity is also reduced due to long-term use of antibiotics, cytostatics and corticosteroids. The risk of the disease is increased among patients who have undergone surgery or chemotherapy.

Chronic diseases of the respiratory system

Pathogenic fungi like to settle on already affected tissues. Pathology is often diagnosed in people suffering from bronchial asthma, chronic bronchitis and cystic fibrosis. Patients with oncology, tuberculosis or lung obstruction are also at risk.

Abundant seeding

Even if a person is absolutely healthy and everything is in order with his immunity, he can also get pulmonary aspergillosis, if often and in large quantities inhales fungal spores. Usually this professional problem, and it concerns workers of mills, spinning and poultry farms, plumbers, farmers, brewers. Even pharmacists, librarians and mushroom pickers are at risk.

Ways of infection

Aspergillus is widespread. They live in air, soil and water, even distilled. Fungi feel comfortable in ventilation and water pipes. There are a lot of them in baths, bathrooms and pools.

On the street, microorganisms are found in the ground, rotting grass, and reservoirs. There are more colonies in the premises. They live in furniture and under wallpaper. They are easy to activate during repairs or when rearranging old furniture.

Among household items increased danger exhibit shabby books, clothes and bedding, as well as air conditioners and humidifiers. This list also includes pots with indoor plants. Occasionally, fungi are found in food. This is especially true for stale vegetables and bulk products: cereals, flour, tea, etc.

In terms of the prevalence of aspergillus in the air, Sudan and Saudi Arabia occupy the first place among countries. Tourists visiting this region often get sick. But microorganisms can only be obtained from the environment. The pathology is not transmitted from person to person.

Disease classification

Allocate four clinical forms illness. They differ in symptoms and features of development. Each requires a special diagnosis and treatment and carries a certain danger to the body.

Invasive pulmonary aspergillosis

Occurs when fungi enter epithelial tissues respiratory tract. Common among immunosuppressed patients. Recently, there have been cases of morbidity among people who are not at risk: patients and hospital staff. On the early stages foci are small seals on the pleura associated with vessels. Gradually, they turn into cavities filled with pus. The process causes tissue death.

Chronic necrotizing aspergillosis

It accounts for 5% of all cases of pulmonary aspergillosis. It occurs predominantly in middle-aged men. Does not always depend on the level of immunity and may develop due to high content fungi in the air or against the background of other pathologies of the respiratory tract. With a disease, a cavity is formed on the wall of the lung, surrounded by inflamed tissues.

Aspergilloma

Otherwise called "mushroom ball". It is a mass of aspergillus. Colonies grow in cavities formed by other diseases: tuberculosis, cancer, pneumonia, etc. The disease does not depend on immune status patient. In 10% of cases, all symptoms disappear without a trace, even in the absence of treatment.

Allergic bronchopulmonary aspergillosis

It is diagnosed in patients with a predisposition to allergies. Allergic pulmonary aspergillosis is often detected in children with impaired immune systems. The reaction occurs on fungi and their metabolic products. No tissue destruction was noted. The disease is chronic, periods of remission are replaced by exacerbations.

Symptoms of pulmonary aspergillosis in humans

The clinical picture depends on the type of disease. In the invasive form, a high temperature rises and lasts for several days. Patients develop dry cough, hemoptysis. They complain of shortness of breath and chest pain. In persons with very weak immunity symptoms may not even be late stages life threatening.

Necrotizing aspergillosis is characterized by a sluggish course with periodic exacerbations. Patients develop cough with sputum. Blood is released in small quantities. Fever rarely occurs. There is weakness and weight loss.

Aspergilloma on initial stages does not show itself. With the development of the disease, a cough appears, the temperature rises slightly. Most patients experience hemoptysis at least once. With complications, pulmonary bleeding is possible.

With the allergic nature of the disease, attacks of suffocation occur, coughing and chest pain. Breathing difficult, wheezing. Mucus and brown lumps appear in the sputum. Body temperature rises.

Common symptoms include weakness, sleep disturbance, lack of appetite. A characteristic sign of pathology is the taste of mold in the mouth.

Diagnostics

First of all, if aspergillosis is suspected, the medical history is studied and the patient is interviewed. It is necessary to find out the living and working conditions, to identify the presence of dangerous working conditions. The presence of diabetes mellitus and other chronic diseases in history is also checked. The duration and prescription of taking antibiotics and other potent drugs is specified.

Laboratory tests include a blood test to evaluate the number of white blood cells and eosinophils. Serology helps to check for the presence of antibodies. Sputum examination allows you to determine the type of pathogen.

With bronchoscopy, deformations of the trachea and bronchi are detected, foci of inflammation are determined. During the procedure, plaque is taken from the tissues for analysis. A chest x-ray is also taken.

MSCT, or multispectral computed tomography, is the main method for detecting lesions. Damaged areas in pulmonary aspergillosis have specific kind, which can only be fully appreciated with high resolution equipment.

Differential diagnosis of aspergillosis with tuberculosis, sarcoidosis, destructive pneumonia, and cancer is necessary. You may need to consult a phthisiatrician and an oncologist. All patients in without fail are referred to an otolaryngologist.

Treatment Methods

The duration and characteristics of the treatment of pulmonary aspergillosis depends on the type and severity of the disease, the state of immunity. Mild forms are cured on an outpatient basis in a week and a half. AT difficult cases therapy is delayed for a year. The indication for hospitalization is hemoptysis.

Medical treatment

Patients are prescribed antifungal antibiotics. Use drugs in the form of tablets, inhalations and injections. Corticosteroid hormones are also indicated to eliminate blockage of the bronchi with mucus. Needed for allergies antihistamines. Asymptomatic aspergilloma and allergic form in remission, no treatment is needed.

Surgery

It is indicated in the presence of bleeding and is combined with conservative treatment. Mandatory sanitation of the affected foci. In some cases, removed part of a lung or the whole organ. In case of respiratory failure, ligation of the bronchial artery is used as a temporary measure.

Possible Complications

The most common complication is pulmonary hemorrhage. It is also possible to develop abundant suppuration and subsequent deformation of the bronchi. In some cases, fungal spores penetrate the vessels, the infection spreads through the bloodstream throughout the body and affects various organs.

At chronic course develops cor pulmonale. With this pathology, the right parts of the organ expand and increase. The condition threatens with disability. Frequent deaths.

Forecast

In mild forms, the prognosis is favorable. Competent treatment leads to full recovery. In the absence of proper therapy, the disease passes into the chronic stage.

Invasive aspergillosis without treatment almost always ends in death of the patient within a month after infection. Even timely health care sometimes it doesn't help. Mortality from this form of the disease reaches 50%. Patients with immunodeficiency and patients taking large doses glucocorticosteroids before diagnosing pathology.

Prevention

It is important for people with reduced immunity to be regularly examined for aspergillus carriage. When working in hazardous industries, they need to wear a respirator. And if fungi are found in the analyzes, a change of work is required.

Immunocompromised patients treated in a hospital should be regularly disinfected and air filtered. It is forbidden to keep indoor plants in the chamber.

It is recommended to refuse agricultural work and contact with animals. You can not eat stale foods and cheeses with mold. If possible, stay in damp and dusty areas should be avoided. In the house, it is important to periodically clean the ventilation, air conditioners and humidifiers.

An important measure is to strengthen the immune system. It is useful to use vitamin complexes, exercise and walks on fresh air. Infectious diseases should be treated in a timely manner and antibiotics and other potent drugs should not be taken unnecessarily. It is highly recommended to stop using alcohol and drugs.

Aspergillosis of the lungs insidious disease. You can get it anywhere. Although in most cases the body successfully copes with fungi, but with a weakened immune system, the risk of disease increases significantly. The lower protective functions the more severe the pathology.

Aspergillosis of the lungs infection fungal etiology. It develops mainly in people with a weakened immune system. In addition to the respiratory system, the infection can affect the central nervous system, mucous membranes, and skin. Aspergillosis is detected in a timely manner only in 25% of cases, which is associated with the absence of specific symptoms of the disease and the imperfection of diagnostic methods.

The causative agent of aspergillosis

The disease is caused by pathogenic fungi belonging to the genus Aspergillus. There are 15 species dangerous to humans. All members of the genus Aspergillus are widely distributed in the environment.

They live in the soil, ventilation shafts, air conditioners, humidifiers, the walls of old houses, rags, potted plants, food. High humidity and heat promote the reproduction of aspergillus. Fungal spores are found in large quantities in household and construction dust. Most often, construction workers, agricultural workers, and poultry farmers come into contact with the pathogen..

Aspergillus aerobes and heterotrophs, resistant to drying and freezing. They are adapted to survive in the human environment. Fungal enzymes - keratinase and elastase - are able to destroy lung tissue. A. flavus releases toxins into human blood.

Infection most often occurs by inhalation of spores of the fungus. Less often, the infection enters the human body with food or through an open wound. It is also possible transplacental transmission of aspergillosis from mother to child and autoinfection in case of fungal infection of the skin and mucous membranes.

Aspergillus grows in culture on Sabouraud, Chapek-Dox, wort-agar media. Colonies are formed in 2-4 days. Aspergillus can withstand temperatures up to 40 0 ​​C and above. Colonies are white, fluffy, round shape darken over time. Separate types are yellow, green and black.

Factors predisposing to infection with aspergillosis

At risk are people who have undergone lung transplantation and have chronic diseases of the respiratory system:

• bronchial asthma,
• tuberculosis,
• emphysema,
• sarcoidosis,
• histoplasmosis,
• lung abscess,
• burns and lung injuries
• tumors,
• bronchiectasis.

Also, the likelihood of contracting pulmonary aspergillosis increases with systemic pathologies that reduce immunity, such as AIDS, diabetes mellitus, aplastic anemia, cystic fibrosis. The body's resistance decreases when smoking, long-term use antibiotics, cytostatics and hormonal drugs, frequent use alcohol after surgery. The disease can develop in people with congenital disorders immune system.

Disease pathogenesis

Not in all cases, contact with the pathogen leads to aspergillosis.

When it enters the lungs of a healthy person, most of the fungal spores are neutralized by the mucociliary system of the respiratory tract. Tissue macrophages phagocytize the remaining fungal spores, preventing the growth and reproduction of aspergillus. Fungal hyphae are too large for alveolar macrophages. protection from invasive growth Aspergillus is carried out by neutrophils. Thus, there are three lines of defense of the body against infection by pathogenic fungi.

With chronic neutropenia or a decrease in the activity of phagocytes with their normal number, fungi begin to actively colonize the mucous membranes of the lower respiratory tract. They are able to grow walls blood vessels resulting in bleeding and thrombosis.

Aspergillus spores spread throughout the body through the bloodstream, affecting other organs. Most often, disseminated aspergillosis affects the heart, kidneys, brain, liver, bone tissue, eyes, and hearing aid.

At normal functioning of the immune system in the lungs, an isolated focus of pathology is formed - aspergilloma. This is a cavity surrounded by a capsule, inside which there are mucus, pus, fungal hyphae, fibrin. Fungi can colonize the cavities that have arisen in the lungs as a result of chronic diseases.

The causative agents of aspergillosis secrete poison - aflatoxin, which causes cirrhosis of the liver, have a carcinogenic effect. In patients with immunodeficiencies, combined mycoses develop - candidiasis joins aspergillosis.

Disease classification

Aspergillosis of the lungs is divided into the following types:

• acute invasive aspergillosis,
• chronic necrotizing aspergillosis,
• allergic bronchopulmonary aspergillosis,
• invasive aspergillus tracheobronchitis,
• ulcerative aspergillus tracheobronchitis,
• pseudomembranous aspergillus tracheobronchitis.

The division of pathology into aspergillosis of the lungs and tracheobronchial tree is conditional, because usually the disease affects the entire respiratory system. The causative agent often affects the peripheral areas of the lungs. The tracheobronchial tree is entrance gate for a fungal infection.

A special position is occupied by disseminated aspergillosis, which develops with immunodeficiencies. Acute and chronic forms of the disease require different methods of diagnosis and treatment.

Signs of illness

Acute aspergillosis has the following symptoms in humans:

• increase in body temperature,
• dry cough,
• dyspnea.

For the acute form of the disease, sputum with blood is not characteristic. Fever may be mild in people taking corticosteroids. Shortness of breath often appears with tracheobronchitis.

In chronic aspergillosis appears paroxysmal cough with thick sputum of mucous consistency and gray color. Sometimes there are blood clots in the sputum. A person feels pain in the chest, loses appetite, loses weight, gets tired quickly. The patient's breath becomes characteristic odor mold.

Allergic bronchopulmonary aspergillosis develops mainly in patients with atopic bronchial asthma. The main symptoms of aspergillosis in such patients are accompanied by an increase in asthmatic attacks.

Diagnostics

A patient with suspected pulmonary aspergillosis is referred to a pulmonologist or mycologist. For the doctor, the patient's history is of great importance:

• the presence of professional risks,
• congenital or acquired immunodeficiency,
• taking glucocorticoids and cytostatics,
• chronic lung diseases,
• undergone organ transplants.

Standard procedures are followed:

• bronchoscopy,
• thoracoscopic biopsy,
• transthoracic puncture.

To isolate the pathogen, sputum obtained as a result of bronchoscopy is examined. Determination of the culture of the fungus takes from 3 to 5 days. The result obtained is far from always reliable, since there is a possibility of Aspergillus from external environment. Therefore, it is recommended to combine microbiological research with microscopy of sputum or alveolar washings. Aspergillus are identified by the characteristic arrangement of hyphae and conidia.

In the early stages of the disease, one of the most informative methods diagnosis is computed tomography. Examination of the patient's lungs reveals multiple foci of darkening with a diameter of 1-3 cm. Seals of the tissue around the foci are edema or a consequence of hemorrhage and are regarded as early signs of aspergillosis. At chronic disease areas of necrosis appear in the shape of a crescent or meniscus. Aspergillosis often affects the peripheral areas of the lungs.

X-ray examination helps to detect cavities associated with the pleura in the later stages of the disease. To detect antibodies to a pathogen in the blood, a method is used enzyme immunoassay. Using PCR, the presence of aspergillus DNA in the blood is checked. When diagnosing invasive mycoses, fragments of the cell wall of fungi and their metabolic products are determined in the blood.

To diagnose allergic aspergillosis, skin tests with fungal antigens are performed. In the patient's blood, the level of eosinophils rises and IgE and IgG to aspergillus appear against the background of exacerbation of bronchial asthma.

To control the general condition of the patient, a general and biochemical analysis blood, urinalysis. Aspergillosis is differentiated from other mycoses, tuberculosis, cancer, pneumonia, cystic fibrosis, viral and bacterial infections.

Medical treatment

Treatment of aspergillosis is carried out both at home and in a hospital. The most common drugs used for fungal infections are amphotericin B and antifungal triazoles.

Antifungal triazoles are a large group of drugs that include voriconazole, itraconazole, ravoconazole, posaconazole, etc. The choice of the drug should be made by the attending physician, focusing on the severity of the disease, its form and the presence of concomitant pathologies. Triazoles inhibit the synthesis of ergosterol, a structural element cell membrane aspergillus, which leads to cell death. Cell division of fungi is disrupted, growth stops. Preparations for intravenous administration and in the form of tablets are produced. In patients at risk, the level is monitored medicinal substances in the blood to prevent the development of side effects.

Amphotericin B - macrolide antibiotic, which acts on fungi by binding to ergosterol. Also, the drug causes a cascade of oxidative reactions that destroy the cells of the pathogen. Amphotericin B is used as intravenous injections. The main disadvantage of the drug are severe adverse reactions such as bronchospasm, headache, nausea, vomiting. Its long-term use can cause kidney failure. With caution, Amphotericin B is prescribed to diabetics, patients with diseased kidneys and bone marrow recipients. Liposomal forms of Amphotericin B have been developed with less toxicity.

Echinocandins - Caspofungin, Micafungin and Anidulafungin are also used for aspergillosis. These drugs inhibit the synthesis of pathogen cell wall polysaccharides, which are responsible for maintaining the shape and strength of the cell. Medicines are administered only intravenously and can be used in combination with other antifungal agents.

It is recommended to start treating aspergillosis with voriconazole. In severe forms of the disease, preference is given to intravenous administration drugs. The second line of therapy includes Amphotericin B in combination with Itraconazole or Caspofungin. When choosing drugs, it should be taken into account that the resistance of various types of aspergillus to active ingredient drug may vary. The duration of treatment varies from 2 to 12 weeks. Patients with immunodeficiencies should take antimycotics until the immune system is restored.

Surgical treatment of aspergillosis

Surgical treatment is performed for local invasive forms of pulmonary aspergillosis. There are three main indications for intervention:

• the threat of violation of the integrity of the walls pulmonary artery,
• the need to reduce the volume of fungal masses before bone marrow transplantation or chemotherapy,
• open lung biopsy to confirm the diagnosis.

Pulmonary hemorrhages are the cause of death in patients with neutropenia in 10-15% of cases. During the period when immunity is reduced, aspergillus grows in the bronchi and penetrates into small vessels causing local hemorrhages. When the function of the bone marrow is restored, the content of phagocytes in the tissues increases. Leukocytes attack pathogen cells with the help of proteolytic enzymes. In this case, sections of the lung tissue are destroyed.

If the lesion is located near the pulmonary artery, immune response can cause perforation of the arterial wall, resulting in severe pulmonary bleeding.

For patients with aspergillosis, the period of restoration of the number and activity of granulocytes is most dangerous. Surgery reduces the risk of complications after bone marrow transplantation, especially if one or two lobes of the lung can be removed.

Treatment of allergic aspergillosis

Allergic aspergillosis is often confused with therapy-resistant asthma or tuberculosis. Absence proper treatment leads to the development of severe forms of the disease. The patient develops a lot of bronchiectasis, pneumofibrosis, the function of external respiration is disturbed.

Treatment of allergic pulmonary aspergillosis is carried out in two stages. At the acute stage of the disease, systemic glucocorticosteroids are prescribed to relieve obstruction. Taking antifungal drugs during this period can cause a sharp deterioration in the patient's condition, which is associated with the appearance of a large number of antigens during the decay of aspergillus. Application inhaled corticosteroids with pronounced inflammatory process and a large amount of sputum is considered ineffective. Inhalations are used during remission to prevent the recurrence of bronchial asthma.

At the second stage of treatment, antifungal drugs are introduced. The purpose of their appointment is to remove the pathogen from the respiratory tract of the patient, where Aspergillus act as a constant source of antigens. In allergic aspergillosis, itraconazole is most commonly used. Other medicines applied in isolated cases.

During the treatment period, the level of class E immunoglobulins is monitored. An increase in IgE indicates a poor effectiveness of the treatment received and the development of an obstructive syndrome.

The duration of treatment varies from 1 to 8 months. Properly selected therapy helps to achieve stable remission. After recovery, patients are recommended to periodically undergo an examination, including the determination of the content of IgE in the blood and the diagnosis of the state of the respiratory system. This will help to detect a recurrence of the disease in a timely manner.

Disease prevention

Methods for the primary prevention of aspergillosis do not yet exist. Attempts have been made to prevent the development of the disease in immunocompromised patients with inhaled amphotericin B and oral itraconazole, but these measures have been found to be ineffective. The only way protection against disease for people at risk is a timely examination.

Pulmonary aspergillosis is one of the most common nosocomial infections. Compliance with sanitary norms in hospital premises, installation of filters for air purification in the wards, timely repairs. People working with earth, animals, building materials should use protective masks.