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Fungi and the lung

Aspergillus This group of fungi affects the lung in 5 ways:

  1. Asthma: Type I hypersensitivity (atopic) reaction to fungal spores.
  2. Allergic bronchopulmonary aspergillosis (ABPA):
  3. Aspergilloma
  4. Invasive aspergillosis
  5. Extrinsic allergic alveolitis
  1. ABPA
    1. This results from a Type I and III Q hypersensitivity reaction to Aspergillus fumigatus.
    2. Early on, the allergic response causes bronchoconstriction, but as the inflammation persists, permanent damage occurs, causing proximal bronchiectasis Q
    3. Symptoms: wheeze, cough, sputum (plugs of mucus containing fungal hyphae), dyspnoea and recurrent pneumonia Q.  

Table - Diagnostic Features of ABPA (Ref. Hari. 18th ed., Pg- 2120)



  1. Episodic bronchial obstruction (asthma) (LQ 2012)
  2. Peripheral blood eosinophilia (> 1000/mm3)
  3. Elevated serum IgE concentrations (> 1000ng/ml)
  4. Immediately type skin reactivity to Aspergillus antigens
  5. Precipitating serum antibodies (precipitants) against Aspergillus antigens
  6. Elevated serum IgE and/or IgG antibodies specific to A. fumigatus*
  7. History of pulmonary infiltrates (transient/fleeting or fixed) on chest radiographs or CT scans
  8. Central proximal bronchiectasis on chest CT (LQ 2012) 

Other diagnostic features

  1. History of brownish plugs in sputum
  2. Culture of A. fumigatus from sputum
  3. Elevated IgE (and IgG) class antibodies specific for A. fumigatus 


  1. CXR (transient segmental collapse or consolidation, proximal bronchiectasis)
  2. Aspergillus in sputum; positive aspergillus skin test and/or aspergillus-specific IgE RAST (radioallergosorbent test); positive serum precipitins; eosinophilia; raised serum IgE. 


  1. Prednisolone           
  2. Bronchodilators  

Recent Advances: Voriconazole (azole Antifungal)  is for Acute invasive aspergillosis

  1. Aspergilloma (mycetoma): A fungus ball within a pre-existing cavity (often caused by TB, sarcoidosis). It is usually asymptomatic but may cause cough, hemoptysis (may be torrential), lethargy, weight loss.


  1. CXR. (round opacity within a cavity, usually apical)
  2. Sputum culture
  3. Strongly positive serum precipitins Q;
  4. Aspergillus skin test.

Treatment (only if symptomatic). Consider surgical Q excision for solitary symptomatic lesions or severe hemoptysis. Oral itraconazole Q and other antifungals have been tried with limited success.

  1. Invasive aspergillosis: Risk factors
    1. Immunocompromised, eg HIV, leukemia.
    2. Burns,
    3. WEGENER'S granulomatosis
    4. SLE
    5. After broad-spectrum antibiotic therapy.


  1. Sputum culture
  2. Serum precipitins;
  3. CXR (consolidation, abscess).
  4. Iv. Chest CT
  5. Serial serum measurements of galacto mannan (an Aspergillus antigen) can be very helpful.
  6. Diagnosis may only be made at lung biopsy Q or autopsy.

Treatment: Amphotericin Q B.

  1. Extrinsic allergic alveolitis (hypersensitivity pneumonitis)  is caused by sensitivity to Aspergillus clavatus (malt worker's lung' Q). It is an inflammatory disorder of lungs involving alveolar walls & terminal airways that I induced in a susceptible host by repeated inhalation.

Prediction rule applies to hypersensitivity pneumonitis. (Ref. Hari. 18th ed., Pg- 2118)

  1. Exposure to known antigen.                                     
  2. Presence of positive antibody to exposed antigen.
  3. Recurrent symptoms                        
  4. Inspiratory crackles
  5. Symptoms occur after 4 to 8 hrs after exposure.      
  6. Weight loss.   

Diagnosis is based on a history of exposure and presence of serum precipitins to A. clavatus.

Pulmonary fibrosis Q may occur if untreated.


Difference between ABPA & Wegner’s Granulomatosis




Age of presentation

Most of the age range is 20-40 years

Mean age at diagnosis is 50 years

Fever, weight loss, hemoptysis

May be seen

May be seen


Not associated

Pauciarticular (oligoarticular), or polyarticular arthritis may be seen

Fleeting opacities in CXR

May be seen

May be seen


Extra Edge:

Other fungal infections Candida and Cryptococcus may cause pneumonia in the immunosuppressed.
Coccidiomycoses: It causes desert rheumatism
Histoplasmosis:  It CXR finding resemble like miliary TB.

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