Skip to main content

Main menu

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • COVID-19 submission information
    • Institutional open access agreements
    • Peer reviewer login
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • COVID-19 submission information
    • Institutional open access agreements
    • Peer reviewer login
  • Alerts
  • Subscriptions

Pulmonary aspergillosis: diagnosis and treatment

Frederic Lamoth, Thierry Calandra
European Respiratory Review 2022 31: 220114; DOI: 10.1183/16000617.0114-2022
Frederic Lamoth
1Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
2Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: Frederic.Lamoth@chuv.ch
Thierry Calandra
1Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Figures

  • Tables
  • FIGURE 1
    • Download figure
    • Open in new tab
    • Download powerpoint
    FIGURE 1

    Schematic representation of the diagnostic classification of invasive pulmonary aspergillosis (IPA) according to the European Organization for Research and Treatment of Cancer and Mycoses Study Group Education and Research Consortium. Possible IPA must include at least one host criterion and one clinical criterion. Probable IPA must include at least one host criterion, one clinical criterion and one mycological criterion. Proven IPA is defined independently from the presence or absence of host/clinical/mycological criteria. For details, see reference [9]. BAL: bronchoalveolar lavage; CT: computed tomography; PCR: specific polymerase chain reaction for Aspergillus species.

  • FIGURE 2
    • Download figure
    • Open in new tab
    • Download powerpoint
    FIGURE 2

    Diagnostic approach of invasive pulmonary aspergillosis (IPA) in high-risk haematologic cancer patients. AF: antifungal; BAL: bronchoalveolar lavage; CT: computed tomography; EORTC/MSGERC: European Organization for Research and Treatment of Cancer and Mycoses Study Group Education and Research Consortium; GM: galactomannan; GVHD: graft versus host disease; HSCT: haematopoietic stem cell transplantation; IA: invasive aspergillosis; MRI: magnetic resonance imaging; ODI: optical density index; PCR: specific polymerase chain reaction for Aspergillus species.

Tables

  • Figures
  • TABLE 1

    Characteristics of nonculture commercialised diagnostic tests for invasive pulmonary aspergillosis

    TargetType of test (manufacturer)TechniqueSpectrum of detectionType of sampleCut-off
    GalactomannanPlateliaTM Aspergillus EIA (Bio-Rad)Immunoenzymatic sandwich assayAll Aspergillus species (specific)#Serum, BAL0.5–1.0 ODI¶
    Soña Aspergillus galactomannan LFA (IMMY)Immunochromatographic assay (LFA)Visual reading or cube reader: 0.5–1.0¶ (index values)
    Aspergillus galactomannan VirCliaTM (Vircell)Chemoluminescent assay1.0 (index value)
    (1→3)-β-d-GlucanFungitellTM (Associates of Cape Cod)Colorimetric assay (microplate)All Aspergillus species (not specific)+Serum60–80 pg·mL−1§
    Fungitell STATTM (Associates of Cape Cod)Colorimetric assay (single tube)0.75–1.2 (index values)§
    Wako β-glucan test (Fujifilm Wako Chemicals)Turbidimetric assay (single tube)7.0 pg·mL−1
    Dynamiker Fungus (1–3)- β-d-glucan (Dynamiker Biotechnology)Colorimetric assay (microplate)70–95 pg·mL−1§
    Aspergillus DNAMycAssay AspergillusTM (Myconostica Ltd., now Microgen Bioproducts Ltd.)Real-time PCR (18S rDNA)Most relevant Aspergillus speciesBAL, other respiratory samples, serumNA
    AsperGeniusTM (PathoNostics)Multiplex real-time PCR (28S rDNA and Cyp51A)Most relevant Aspergillus species, Cyp51A mutations (L98H, TR34, T289A, Y121F)NA
    MycoGenieTM (AdemTech)Real-time PCR (28S rDNA and Cyp51A)Aspergillus fumigatus, Cyp51A mutations (L98H, TR34)NA
    Fungiplex Aspergillus azole-RTM (Bruker Daltonics GmbH)Multiplex real-time PCRAspergillus species, Cyp51A (TR34, TR46)NA

    Note: the table is limited to the most relevant currently available test methods. BAL: bronchoalveolar lavage; EIA: enzyme immunoassay; LFA: lateral flow assay; NA: not applicable; ODI: optical density index. #Cross-reaction with some other fungal pathogens, e.g. Fusarium, Histoplasma. ¶ODI 0.5 is recommended by the manufacturer. Higher cut-offs (e.g. 1.0) are recommended for better specificity, notably in non-serum samples (BAL, cerebrospinal fluid). +Detection of most other fungal pathogens with some exception (e.g. Mucorales). §Values below, within and above this range are considered as negative, indeterminate and positive, respectively.

    • TABLE 2

      Performance of galactomannan (GM) and Aspergillus PCR in serum and bronchoalveolar lavage fluid (BAL) for the diagnosis of invasive pulmonary aspergillosis (IPA) in haematologic cancer patients: results of the most relevant meta-analyses

      Fungal biomarkerStudySensitivity (%) (95% CI)Specificity (%) (95% CI)
      Serum
       GMPfeiffer et al. [38]58 (52–64)95 (94–96)
      Leeflang et al. [98]¶78 (70–85)85 (78–91)
      Arvanitis et al. [28]92 (83–96)90 (81–95)
       PCRMengoli et al. [99]88 (75–94)75 (63–84)
      Arvanitis et al. [28]84 (71–92)76 (64–85)
       GM and PCR#Arvanitis et al. [28]99 (96–100)98 (94–100)
      BAL
       GMGuo et al. [100]¶85 (72–93)94 (89–97)
      Avni et al. [29]¶85 (62–95)100 (97–100)
      Zou et al. [101]¶86 (76–92)95 (91–97)
      Heng et al. [30]75 (55–88)95 (87–98)
      De Heer et al. [102]¶78 (61–95)93 (87–98)
       PCRSun et al. [103]¶91 (79–96)92 (87–96)
      Avni et al. [29]¶93 (70–98)98 (93–99)
      Zou et al. [101]¶82 (61–93)98 (85–100)
      Heng et al. [30]57 (31–80)99 (60–100)
       GM and PCR#Avni et al. [29]¶97 (83–99)97 (93–99)
      Heng et al. [30]84 (79–88)94 (91–97)

      Results are displayed for the diagnosis of proven and probable IPA. For GM, results are displayed for the cut-off of optical density index 0.5 for serum and 1.0 for BAL. #Where a positive result is considered as either GM or PCR positive and a negative result as both GM and PCR negative. ¶Mixed populations, but with a predominance of haematologic cancer patients.

      • TABLE 3

        Antifungal agents for the treatment of pulmonary aspergillosis

        Antifungal classDrugsDosageTherapeutic useComments
        PolyenesDeoxycholate amphotericin B1–1.5 mg·kg−1 once daily (intravenous only)Should be avoided (privilege lipid formulations of amphotericin B if available)Monitor kidney function and electrolytes (K+)

        Consider co-administration of paracetamol if fever and/or rigors

        Consider alternative therapy for Aspergillus terreus
        Liposomal amphotericin B3–5 mg·kg−1 once daily (intravenous only)Treatment of IPA (second choice after triazoles; first choice in areas with high prevalence of azole-resistant Aspergillus fumigatus isolates if no culture/fungigram available)
        Amphotericin B lipid complex5 mg·kg−1 once daily (intravenous only)Treatment of IPA (privilege liposomal amphotericin B if available)
        Amphotericin B colloidal dispersion6 mg·kg−1 once daily (intravenous only)Treatment of IPA (privilege liposomal amphotericin B if available)
        TriazolesItraconazole200 mg once daily or twice daily (intravenous or oral)
        TDM recommended (target: Ctrough: 1–4 mg·L−1)
        Treatment of CPAMonitor hepatic tests (ALT, AST, ALP, GGT, bilirubin)

        Monitor ECG (QT interval, in particular voriconazole)

        DDIs (in particular voriconazole)

        Consider alternative therapy for Aspergillus calidoustus or cryptic species of section Fumigati (e.g. Aspergillus lentulus)
        VoriconazoleIntravenous: 6 mg·kg−1 twice daily (D1), then 4 mg·kg−1 twice daily
        Oral: 400 mg twice daily (D1), then 200–300 mg twice daily
        TDM recommended (target: Ctrough: 1–5 mg·L−1)
        Treatment of IPA (first choice)
        Treatment of CPA
        PosaconazoleIntravenous or oral tablets: 300 mg twice daily (D1), then 300 mg once daily
        Oral suspension: 200 mg three times daily
        TDM recommended (target: Ctrough: >1 mg·L−1 for therapy and >0.7 mg·L−1 for prophylaxis)
        Prophylaxis or treatment of IPA
        Treatment of CPA (privilege itraconazole or voriconazole)
        Oral suspension should be avoided or limited to prophylaxis (privilege intravenous formulation or oral tablets)
        Isavuconazole200 mg three times daily (D1–2), then 200 mg once daily
        TDM not routinely recommended (may be considered)
        Treatment of IPA
        Treatment of CPA (privilege itraconazole or voriconazole)
        EchinocandinsCaspofungin70 mg (D1), then 50 mg once daily (intravenous only)Treatment of IPA as monotherapy (third choice after triazoles and lipid formulations of amphotericin B)
        Treatment of IPA in combination with triazoles (severe cases and/or positive GM; azole-resistant Aspergillus fumigatus isolates)
        Anidulafungin200 mg (D1), then 100 mg once daily (intravenous only)
        Micafungin100 mg once daily (intravenous only)

        ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate aminotransferase; CPA: chronic pulmonary aspergillosis; D1: day 1; DDI: drug–drug interaction; GGT: gamma glutamyltranspeptidase; GM: galactomannan; IPA: invasive pulmonary aspergillosis; TDM: therapeutic drug monitoring, W1: week 1.

        PreviousNext
        Back to top
        View this article with LENS
        Vol 31 Issue 166 Table of Contents
        European Respiratory Review: 31 (166)
        • Table of Contents
        • Index by author
        Email

        Thank you for your interest in spreading the word on European Respiratory Society .

        NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

        Enter multiple addresses on separate lines or separate them with commas.
        Pulmonary aspergillosis: diagnosis and treatment
        (Your Name) has sent you a message from European Respiratory Society
        (Your Name) thought you would like to see the European Respiratory Society web site.
        CAPTCHA
        This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
        Print
        Citation Tools
        Pulmonary aspergillosis: diagnosis and treatment
        Frederic Lamoth, Thierry Calandra
        European Respiratory Review Dec 2022, 31 (166) 220114; DOI: 10.1183/16000617.0114-2022

        Citation Manager Formats

        • BibTeX
        • Bookends
        • EasyBib
        • EndNote (tagged)
        • EndNote 8 (xml)
        • Medlars
        • Mendeley
        • Papers
        • RefWorks Tagged
        • Ref Manager
        • RIS
        • Zotero

        Share
        Pulmonary aspergillosis: diagnosis and treatment
        Frederic Lamoth, Thierry Calandra
        European Respiratory Review Dec 2022, 31 (166) 220114; DOI: 10.1183/16000617.0114-2022
        Reddit logo Technorati logo Twitter logo Connotea logo Facebook logo Mendeley logo
        Full Text (PDF)

        Jump To

        • Article
          • Abstract
          • Abstract
          • Introduction
          • Diagnosis
          • Treatment
          • Conclusions
          • Footnotes
          • References
        • Figures & Data
        • Info & Metrics
        • PDF

        Subjects

        • Respiratory infections and tuberculosis
        • Tweet Widget
        • Facebook Like
        • Google Plus One

        More in this TOC Section

        Series

        • Supplemental oxygen and noninvasive ventilation
        • Nonpharmacological management of psychological distress in COPD
        • Lung transplantation for COPD/pulmonary emphysema
        Show more Series

        Respiratory infections

        • New antibiotics for Gram-negative pneumonia
        • Severe community-acquired pneumonia
        Show more Respiratory infections

        Related Articles

        Navigate

        • Home
        • Current issue
        • Archive

        About the ERR

        • Journal information
        • Editorial board
        • Press
        • Permissions and reprints
        • Advertising
        • Sponsorship

        The European Respiratory Society

        • Society home
        • myERS
        • Privacy policy
        • Accessibility

        ERS publications

        • European Respiratory Journal
        • ERJ Open Research
        • European Respiratory Review
        • Breathe
        • ERS books online
        • ERS Bookshop

        Help

        • Feedback

        For authors

        • Instructions for authors
        • Publication ethics and malpractice
        • Submit a manuscript

        For readers

        • Alerts
        • Subjects
        • RSS

        Subscriptions

        • Accessing the ERS publications

        Contact us

        European Respiratory Society
        442 Glossop Road
        Sheffield S10 2PX
        United Kingdom
        Tel: +44 114 2672860
        Email: journals@ersnet.org

        ISSN

        Print ISSN: 0905-9180
        Online ISSN: 1600-0617

        Copyright © 2023 by the European Respiratory Society