Aspergillosis

Disease Description (Causes and Symptoms)

• Definition: Aspergillosis is a group of diseases caused when fungi of the genus Aspergillus (commonly found in the environment) enter the respiratory tract. Depending on immune status and underlying lung disease, it can present in various forms, including allergic, chronic (e.g., pulmonary fungal infection/aspergilloma), and invasive forms.
• Causes/Pathophysiology: Spores found in the environment (soil, decaying plants, grain, indoor air, etc.) are inhaled and reach the lungs. They are controlled by a normal immune system, but in people with weakened immunity or structural lung disease, they can cause invasion, colonization, or an allergic reaction. Invasive disease can cause blood-vessel invasion and tissue necrosis.
• Main symptoms: Cough (with phlegm), blood in the phlegm (hemoptysis), shortness of breath, fever, chills, wheezing, chest pain, and weight loss (in chronic disease), among others. Allergic bronchopulmonary aspergillosis (ABPA) can worsen asthma and cause bronchopulmonary damage. Some chronic pulmonary fungal infections (fungal balls) are initially asymptomatic and gradually cause symptoms.

Treatment Methods

• General principles: Treatment varies depending on the form (allergic vs. chronic noninvasive (fungal ball) vs. invasive). Elimination of the causative fungus, control of inflammation, and management of bleeding and complications are carried out together.
• Medication treatment
  • Invasive aspergillosis: Voriconazole is generally recommended as the first-line medication (the timing and duration of administration and dosage before and during treatment are determined by the physician). Amphotericin B, isavuconazole, or other antifungal agents (including combination therapy with echinocandins) may be used depending on the circumstances. Treatment lasts from several weeks to several months (depending on clinical response and immune recovery).
  • Chronic aspergillosis (including chronic fibrotic forms): Long-term azole therapy (such as itraconazole or voriconazole) may be considered.
  • Allergic bronchopulmonary aspergillosis (ABPA): Oral corticosteroids are the main treatment; in some cases, an azole may be combined to attempt to reduce the steroid dose.
• Procedures and surgery
  • For a pulmonary fungal ball (aspergilloma) with recurrent or massive hemoptysis, surgical resection may be considered. If bleeding is severe, emergency treatment such as embolization may be necessary.
  • Obtaining tissue (biopsy) or drainage may be necessary for invasive lesions.
• Monitoring and management of side effects
  • Azole antifungals require caution regarding hepatotoxicity and drug interactions (especially CYP interactions). Therapeutic drug monitoring (TDM) may be considered for voriconazole. Vision, liver function tests, and drug interactions should be checked.
  • During long-term treatment, liver function, drug levels, and improvement in symptoms should be checked regularly.
• Lifestyle management and precautions
  • People with weakened immunity (including those receiving chemotherapy, hematopoietic stem cell or organ transplants, or high-dose steroids) are advised to reduce exposure to fungi (avoid gardening and decaying materials, avoid construction sites, and remove indoor mold, ventilate, and use a HEPA filter).
  • Immediate emergency evaluation is necessary if bleeding (hemoptysis) occurs.
  • Do not stop taking antifungal medication without consulting the prescribing physician.

Checklist Before an Outpatient Visit (Items to Bring and Example Questions)

• Items to bring (for an outpatient visit/appointment)
  • A list of all medications and supplements currently being taken (especially immunosuppressants, antibiotics, anticoagulants, and antifungals)
  • Copies of recent test results (chest X-ray/CT, blood tests, sputum culture/blood culture results, etc.)
  • A record of when symptoms began and how they have progressed (cough, fever, hemoptysis, shortness of breath, etc.), including factors that worsen or improve them
  • A history of underlying diseases (leukemia, transplant, diabetes, previous tuberculosis or lung disease, etc.)
  • A sputum sample, if possible
• Things to tell the doctor in advance during the outpatient visit
  • Whether you have recently received immunosuppressive treatment (chemotherapy, steroids, or immunosuppressants)
  • The possibility of recent exposure to construction sites, gardening, or mold
  • Any drug allergies and whether you have abnormal liver or kidney function

General Example Questions to Ask the Doctor

• What are the main side effects of this medication (the prescribed antifungal), and what symptoms should I monitor?
• What tests are needed while taking the antifungal (such as liver function tests and blood drug levels), and how often should they be performed?
• Do my immunosuppressive medications (or cancer treatment) need to be adjusted? Is stopping or changing treatment recommended?
• How likely is it that surgery or a procedure (such as lung resection or embolization) will be necessary?
• What is the prognosis? What are the treatment success rate and the risk of recurrence?

Examples of Disease-Specific Questions (1–2)

• A pulmonary fungal ball (aspergilloma) has been confirmed. If I do not have recurrent hemoptysis, is conservative observation possible? When do you recommend surgery?
• Are there any interactions between the medications I am taking (or plan to take) and antifungals (such as voriconazole/itraconazole)? Do I need blood level monitoring?