Aspergillosis: treatment, symptoms, diagnosis,prevention

Update: October 2018 Aspergillosis is a fungal disease
(mycosis) caused by mold fungi of the genus Aspergillus,
manifested predominant lesion of the respiratory system.
Pulmonary aspergillosis is the most common form of mycosis.
respiratory organs.

How does aspergillosis occur? Aspergillus are located
everywhere: on the ground, in the air and in the water. Infection occurs when
airway spores of the fungus along with inhaled
by air. Sources of aspergillus can be showers,
ventilation, split systems, air humidification devices,
inhalations, books, pillows, land in indoor plants, food
products, hay, grass.

The content of aspergillus in the room is higher than in the open air.
The maximum number of mold spores is found in
air from june to october. Exacerbation of the disease occurs more often in
rainy time. Millers are most susceptible to illness,
agricultural workers, library staff, archives, and
also lovers of pigeons breeding them. These harmless
Birds can be a source of human infection. Between people a disease
not passed. Patients suffering from infection are more vulnerable.
diabetes mellitus, asthma, oncological
diseases, immunodeficiencies, weakened, exhausted
sick.

World “leaders” in terms of aspergillosis – Sudan and Saudi
Arabia.

In humans, aspergillosis is characterized by respiratory failure.
system. The main target organs are lungs, bronchi and nasal.
sinus

Statistics

About the relevance of the problem speak dry statistics.
Disseminated form of the disease occurs in 30%, mortality
it is 80%. After transplantation of organs and tissues
invasive pulmonary aspergillosis is formed in every 5th
case, 50% of them end in death. Frequency of occurrence
diseases in reanimation, surgical, burn wards,
HIV-infected, in patients with chronic lung disease,
receiving hormonal corticosteroid therapy is
four%.

Among the invasive forms in the 1st place is pulmonary aspergillosis,
accounting for 90%. The proportion of lesions of the nasal sinuses is 5-10%.
Involvement in the process of the central nervous system (central nervous system) are found
in 1% of cases, it is:

  • abscesses (delimited abscesses) of the brain;
  • meningitis (inflammation of the pia mater);
  • epidural abscesses (abscesses over the solid cerebral
    shell).

Skin aspergillosis is registered in only 5% of patients. is he
manifested by the formation on the surface of the skin with bloody bubbles
content or spots of necrosis (tissue necrosis).
Developed in the area of ​​the venous catheter or in place
dressing.

Among the rare (less than 1%) localizations note:

  • inflammation of the lining of the heart (myocarditis, pericarditis,
    endocarditis);
  • osteomyelitis (inflammation of the bone marrow);
  • peritonitis (inflammation of the peritoneum);
  • esophagitis (inflammatory lesion of the esophagus);
  • lymph node aspergillus damage.

Aspergillus can cause bronchial
asthma, allergic bronchopulmonary aspergillosis,
atopic alveolitis.

ABLA (allergic bronchopulmonary aspergillosis) – pathological
hypersensitivity condition of the lung tissue and its
chronic inflammation influenced by constant exposure 
fungi of the genus Aspergillus. According to ABLA statistics
develops in 7-14% of patients with bronchial asthma who are on
basic treatment of glucocorticoid hormones. Same pattern
persists with cystic fibrosis.

The reasons

There are several varieties of aspergillus. Disease
most often causes A. fumigates, less often A. niger, A. flavus, A.
nidulans, A. terreus, A. clavatus. All these fungi can be
resistant to amphotericin B, sensitivity to voriconazole more often
persists. In addition, A. niger and A. clavatus provoke
development of allergies.

ABPA develops against the background of atopic conditions (asthma,
allergic rhinitis, atopic diathesis, pollinosis).

Pathological changes in the body under the influence
aspergillosis

Aspergillus enters the body through inhalation.
air containing fungi, when they penetrate with food, as well as
settling on the surface of wounds. In favorable conditions
development and growth of the fungus (at high humidity, at a temperature
bodies), the epithelium of the bronchi is populated by aspergillus, with the possibility
their revenues in the bronchi and lungs. This is often combined with
germination of the vascular walls (dangerously bleeding), development
inflammation, the formation of granulomas. Due to the destruction of lung tissue
possible development of pneumothorax (lung collapse and filling
chest cavity air).

Microscopy distinguishes various types of tissue reactions to
introduction of the fungus:

  • serous desquamative;
  • fibrinopurulent;
  • productive, with the organization of granulomas.

Фоновые состояния, способствующие развитию aspergillosis:

  1. Treatment with hormones glucocorticoids at a dose above 5 mg / day (with
    systemic connective tissue diseases ankylosing
    spondylitis). This leads to dysfunction of protective cells –
    T lymphocytes and macrophages.
  2. Chemotherapy with cytotoxic drugs for cancer,
    organ transplantation leading to a decrease in the level of neutrophils in
    blood.
  3. Suppression of granulocyte sprout of blood cells at
    leukemia, chronic granulomatosis, aplastic anemia.
  4. Dysfunction of granulocytes in granulomatosis.
  5. Diabetes.
  6. Chronic diseases of the respiratory system:
    • COPD (chronic obstructive pulmonary disease);
    • cystic fibrosis;
    • bronchiectasis;
    • tuberculosis;
    • sarcoidosis;
    • condition after removal of the lobes or segments of the lung.
  7. Period after surgery, injury.
  8. Peritoneal dialysis (blood purification using the peritoneum,
    is performed in patients with kidney failure when they are not
    cope with their main function – elimination of toxins from
    body). How peritonitis can develop –
    infection of the peritoneum.
  9. Use of venous catheters. With prolonged use
    inflammation of the tissue around the cannula occurs.
  10. Cirrhotic changes in the liver during alcoholism.
  11. General depletion of the body (cachexia).
  12. Severe general condition due to decompensation of chronic
    diseases.
  13. is heкологическая патология.
  14. Long antibiotic therapy.
  15. HIV – infection and other immunodeficiency states.

Perhaps a combination of these factors.

Threatened by the development of fungal allergies are asthmatics,
patients with chronic, recurrent bronchitis, as well as people whose
professional activity associated with mold fungi
(employees of poultry, livestock farms, microbiologists,
pharmacists, pharmacists, librarians, archivists).

Clinic

Symptoms (проявления) aspergillosis зависят от состояния
immunity of the patient. With a good level of immune protection clinic
aspergillosis не выражена. It can be a carrier, colonization,
the formation of aspergillema (limited education with a capsule,
containing aspergilla). With a decrease in immunity develops
invasive form. is heа может иметь острое (о.), подо. or
chronic course. The more pronounced immune disorders, the
more acute clinical manifestations of the disease.

Aspergillosis can be suspected in a patient without even examining
it, by the characteristic smell of mildew from the mouth. It’s easy to explain
because the disease is caused by mold fungi. Feeling such
smell, you need to conduct a focused examination
выявление других признаков aspergillosis.

Aspergillosis papn (sinus nasal sinuses)

О. инвазивный аспергиллез ППН характеризуется
the formation of areas of necrosis (necrosis) of tissues in the area
Aspergillus penetration.

Неинвазивный аспергиллез ППН проявляется в виде
development of one-sided education (aspergilloma). Aspergillema
can persist in one pore, without increasing, for years.

Chronic subclinical invasive aspergillosis
ППН
имеет длительное течение. This is fibrosing inflammation.
with the transition to the brain, the bones of the skull, orbit. Called most often
A. flavus.

With chronic rhinitis, allergic rhinitis, nasal polyps,
especially in conjunction with asthma should look for fungal sinusitis.
With a long course, it is possible that the lattice is erosive.
bones of the skull.

Pulmonary aspergillosis

Aspergillema легких представляет собой
benign colonization developing in the presence of background
states. Morphologically, it consists of a coil of Aspergillus hyphae,
surrounded by a capsule. In the case of the penetration of fungi in the pulmonary
tissue develops hemoptysis associated with damage
vascular wall due to its germination and the influence of toxins.

Radiographically, aspergilloma has the appearance of a rounded
capsule coated molds. Aspergillema darkening intensity
identical liquid. PCR is positive in 95% of cases.

Chronic necrotizing pulmonary aspergillosis
(ХНЛА)
– хроническая or подо. fungal infection. By
symptomatology is intermediate between aspergilloma and
invasive pulmonary aspergillosis. KNLA most difficult for
установки диагноза форма aspergillosis.

There are several forms of HNLA:

  1. Local invasive lesions of the bronchi with the development of bronchiectasis,
    obstruction and necrotic inflammation of the bronchi. Phlegm greenish
    or сероватого цвета. One example is aspergillosis bronchus stump,
    formed after removal of the lung.
  2. Chronic disseminated aspergillosis. Develops with
    inhalation of a large number of spores. Characterized sharply
    delineated areas of necrotic invasive inflammation.
  3. Chronic destructive pneumonia. Other name –
    pseudotuberculosis got the disease due to the similarity of clinical and
    x-ray picture with tuberculosis.

Infiltrates are formed in the upper lobes of the lungs, defined
radiographically. The pictures show thinning of the pleura, can
to be focal dissemination (screening, spread of foci
lesions throughout the lung tissue).

Such patients complain of cough with sputum, raising
temperature, weight loss, hemoptysis. Symptoms
intoxication and fever are less pronounced than in patients with o.
invasive lesion of bronchus, lungs.

О. инвазивный аспергиллез развивается на фоне
reduce immunity. Characterized by the following clinical
signs of:

  • increase in body temperature on the background of antibiotic therapy;
  • negative radiological dynamics in the lungs during treatment
    antibiotics;
  • chest pains;
  • кашель сухой or со скудным количеством мокроты,
    hemoptysis;
  • when listening to the lungs using a phonendoscope are determined
    wheezing, pleural friction noise (the lining of the lungs and thoracic
    cell);
  • combination with sinusitis PPN, complicated bone destruction
    tissue nasal bleeding;
  • the growth of culture aspergillus when sowing discharge from the nasal cavity,
    sputum; blood;
  • detection of fungal mycelium by microscopy;

Forms about. легочного aspergillosis:

  • hemorrhagic infarction;
  • necrotizing pneumonia;
  • endobronchial infection.

Radiographically visible rounded focal shadows located
close to the pleura, around which a halo is defined (this is swelling,
hemorrhage around the lesion).

Aspergillosis of the trachea and bronchi

Аспергиллезные трахеобронхиты – редкое
manifestation of o. инвазивного aspergillosis. Normal develops first
inflammation of the bronchial mucosa. Then it goes into fibrinous
bronchitis with obstruction (blockage) of the lumen. Bronchial colonization
may precede pulmonary aspergillosis.

Allergic bronchopulmonary aspergillosis (ABLA)
патологическое состояние, определяемое сочетанием
following criteria:

  • asthma, especially hormone-dependent, cystic fibrosis;
  • lung tissue infiltrates;
  • positive skin tests with antigen A. fumigatus, definition
    antibodies to it;
  • increase in eosinophils in KLA;
  • the presence of areas of expansion of the bronchi (bronchiectasis), with
    Aspergillus colonization;
  • рост культуры A. fumigatus при посеве материала из мокроты or
    bronchial wash water obtained during bronchoscopy;
  • reduction of VC (lung capacity);
  • increased IgE (antibodies responsible for the development of nonspecific
    allergic reactions).

Features of the clinical picture in childhood

У детей чаще встречаются аллергические формы aspergillosis, что
associated with hypersensitivity to allergens.
The disease is diagnosed since the age of 3 years, since
typical allergic reactions usually occur with this
time when the immune response is already formed. Marked combination
with asthma, allergic dermatitis, adenoids. AT
the clinic is dominated by symptoms of intoxication, bronchospasm, blockage
bronchial mucus.

Diagnostics

When aspergillus is detected in sputum, the following questions are clarified:

  • the presence of occupational hazards;
  • living conditions (predispose to the development of the disease old
    houses with damp, fungus-covered walls, basements
    premises, the location of residential premises near landfills);
  • presence of signs of diabetes, diseases
    nasopharynx;
  • the presence of chronic respiratory diseases;
  • fungal infection of other organs and systems;
  • antibiotic therapy, corticosteroids,
    immunosuppressants.

Laboratory research

To confirm the diagnosis, tests for aspergillosis are performed:

  • sputum microscopy of biopsy material
    aspergillosis;
  • seeding material on special media to obtain culture
    aspergillus;
  • detection of Aspergillus antigens and serum antibodies
    blood;
  • PCR (polymerase chain reaction) diagnostics;
  • кожные пробы (используют для диагностики aspergillosis у
    children).

Byмимо этого косвенными признаками aspergillosis могут
serve:

  • increased levels of eosinophils in the KLA;
  • повышение иммуноглобулина Е в blood.

Instrumental methods

Для диагностики aspergillosis используют методы инструментального
surveys:

  • radiography;
  • spirometry (definition of VC);
  • MRI (magnetic resonance imaging), CT (computerized
    tomography);
  • biopsy;
  • bronchoscopy with wash water analysis.

Consultation of specialists

An otolaryngologist is examined to identify the fungal
lesions of ENT organs, infectious diseases.

Therapy

Лечение aspergillosis должно быть комплексным и включать в себя
main components:

  1. Antifungal therapy. Used drugs: voriconazole,
    амфотерицин AT, интраконазол, каспофунгин, флуцитозин,
    fluconazole.
  2. Normalization of immunity.
  3. Symptomatic (elimination of individual signs of disease)
    treatment:

    • normalization of body temperature;
    • removal of intoxication;
    • elimination of hemoptysis.
  4. Pathogenetic (effect on the links of the pathological
    process) therapy.
  5. Surgical methods. With the ineffectiveness of the conservative
    therapy, continued hemoptysis carry out the removal of the lobe of the lung
    (lobectomy).

The total duration of treatment is from 1 week to
of the year.

Prevention

Preventive measures include:

  1. Primary prophylaxis (prevention of aspergillus in
    respiratory tract) – treatment, purification of air conditioners,
    ventilation systems, air humidifiers, frequent cleaning with
    using disinfectants. Not recommended to breed
    home indoor flowers due to the high content of aspergillus in the soil, and
    also keep pets.
  2. Relapse prevention – rejection agricultural work,
    regular wet cleaning of the room, exclusion of stale food,
    mold products.

Автор: врач-гигиенист, эпидемиолог

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