Page 12 / Case 10.03
– Patchy infiltrates of any of the lower lobes, followed by single focal consolidation, cavitation, and "Crescent sign". A.H.Groll et al mycosis 42,1999
Of 595 patients, 97% had Chest x-rays:
– 70%, compatible with aspergillus: Cavitating infiltrate, nodules, focal infiltrate
– 16% suggestive
– 10% normal
Patterson Thomas et al Med 2000( Baltimore), 2000
Blood culture:
– usually negative
Serology:
– no established value
ELISA:
– utilizes a monoclonal antibody to galactomannan approved for clinical use with a high sensitivity but with high false positive result. Bretagne et al J of inf 97
Biopsy:
– is the gold standard to diagnose pulmonary infiltrate - 80-100% of cases.
Open lung biopsy (OLB)
– specimens are very accurate in determining the cause of pulmonary infiltrate in patients having undergone BMT, but may not improve the outcome. Jordan et al J of ped surg 2002
Chest CT
– Halo sign: nodules surrounded by areas of ground glass attenuation during the neutropenic periods. Air crescent sign: air crescent that surrounds soft tissue lesions during the convalesce from neutropenia have been regarded as specific for IPA. Hyung Jin Won et al Radiology 98
– Segmental areas of consolidation plus ground glass attenuation or at least one nodule with a halo sign were seen in patients with IPA. Won et al Radiology 98
– The crescent sign appears in about half of patients with IPA on recovery from neutropenia. Kim et al Journal of computer assisted tomography 2001
– A large retrospective study in 439 patients treated for aspergillosis
Chest CT scans were done in 156 patients , CT was suggestive of Aspergillosis in 85% ,which include but was not limited to nodule with or without halo sign ,air crescent sign, 12% abnormal but not suggestive of aspergillosis , 3% normal. Patterson Thomas et al Med 2000(Baltimore) 2000
– A Chest CT is more beneficial than the blood test and x-ray for early diagnosis of IPA. Masahiro Kami et al, Haematologica 2000
– A Chest CT is a non-invasive diagnostic test with high utility for early detection of IPA in neutropenic patients. (Of 21/244positive for IPA, all but one had a positive halo sign) A.Hauggaard et al, ACTA radiological,43
Bronchoscopy
– The value of bronchoscopy is controversial. Bronchoscopy allows the diagnosis of IPA in about third of the cases and it is advisable to be done before starting anti-fungal treatment. F. Reichenberger et a lJ of BMT(1999)
– BAL is a useful diagnostic tool for detecting agents of pulmonary infections. (53% =69/119 patients) in patients with hematological malignancies Pagano et al annals of med 97
– Cultures of bronchial wash were positive in 59% (13/22) for aspergillus. Janssen et al intensive care med 96
– The yield of BAL was ~ 40% Levy H et al resp med 86
SENSITIVITY OF BRONCHOSCOPY, CHEST CT, BLOOD CULTURES, IN THE Dx OF ASPERGILLOSIS:
– A retrospective study of 33 patients with invasive aspergillosis CT was, very suggestive of pulmonary aspergillosis 16/19 (77%) and 50% showed angiotrophic lesion, then bronchoscopy and fluid secretion was positive in 8/16 (50%) serology for aspergillus igM positive in 1/13 (8%), non had positive blood culture for aspergillus among 22 patients M.Von Eiff et al, journal of respiration, 1995
– Bronchoscopy has a significant role in treatment of massive hemoptysis, which is rare, but fatal if occurs in patients with IPA. Gorelik et al 2000, the British infection J society
PCR
– There is a considerable clinical value of PCR assay for confirming and improving the diagnosis of IPA in high-risk patients. Buchheidt et al British J of Hem 2002
– Aspergillus PCR on whole blood samples is highly sensitive for the detection of IPA and correlated to tissue invasion Raad et al American cancer society 2002
– PCR was sensitive for the diagnosis of IPA Kami et al clinical infec dis 2001
DIAGNOSTIC TESTS
Chest x-ray:– Patchy infiltrates of any of the lower lobes, followed by single focal consolidation, cavitation, and "Crescent sign". A.H.Groll et al mycosis 42,1999
Of 595 patients, 97% had Chest x-rays:
– 70%, compatible with aspergillus: Cavitating infiltrate, nodules, focal infiltrate
– 16% suggestive
– 10% normal
Patterson Thomas et al Med 2000( Baltimore), 2000
Blood culture:
– usually negative
Serology:
– no established value
ELISA:
– utilizes a monoclonal antibody to galactomannan approved for clinical use with a high sensitivity but with high false positive result. Bretagne et al J of inf 97
Biopsy:
– is the gold standard to diagnose pulmonary infiltrate - 80-100% of cases.
Open lung biopsy (OLB)
– specimens are very accurate in determining the cause of pulmonary infiltrate in patients having undergone BMT, but may not improve the outcome. Jordan et al J of ped surg 2002
Chest CT
– Halo sign: nodules surrounded by areas of ground glass attenuation during the neutropenic periods. Air crescent sign: air crescent that surrounds soft tissue lesions during the convalesce from neutropenia have been regarded as specific for IPA. Hyung Jin Won et al Radiology 98
– Segmental areas of consolidation plus ground glass attenuation or at least one nodule with a halo sign were seen in patients with IPA. Won et al Radiology 98
– The crescent sign appears in about half of patients with IPA on recovery from neutropenia. Kim et al Journal of computer assisted tomography 2001
– A large retrospective study in 439 patients treated for aspergillosis
Chest CT scans were done in 156 patients , CT was suggestive of Aspergillosis in 85% ,which include but was not limited to nodule with or without halo sign ,air crescent sign, 12% abnormal but not suggestive of aspergillosis , 3% normal. Patterson Thomas et al Med 2000(Baltimore) 2000
– A Chest CT is more beneficial than the blood test and x-ray for early diagnosis of IPA. Masahiro Kami et al, Haematologica 2000
– A Chest CT is a non-invasive diagnostic test with high utility for early detection of IPA in neutropenic patients. (Of 21/244positive for IPA, all but one had a positive halo sign) A.Hauggaard et al, ACTA radiological,43
Bronchoscopy
– The value of bronchoscopy is controversial. Bronchoscopy allows the diagnosis of IPA in about third of the cases and it is advisable to be done before starting anti-fungal treatment. F. Reichenberger et a lJ of BMT(1999)
– BAL is a useful diagnostic tool for detecting agents of pulmonary infections. (53% =69/119 patients) in patients with hematological malignancies Pagano et al annals of med 97
– Cultures of bronchial wash were positive in 59% (13/22) for aspergillus. Janssen et al intensive care med 96
– The yield of BAL was ~ 40% Levy H et al resp med 86
SENSITIVITY OF BRONCHOSCOPY, CHEST CT, BLOOD CULTURES, IN THE Dx OF ASPERGILLOSIS:
– A retrospective study of 33 patients with invasive aspergillosis CT was, very suggestive of pulmonary aspergillosis 16/19 (77%) and 50% showed angiotrophic lesion, then bronchoscopy and fluid secretion was positive in 8/16 (50%) serology for aspergillus igM positive in 1/13 (8%), non had positive blood culture for aspergillus among 22 patients M.Von Eiff et al, journal of respiration, 1995
– Bronchoscopy has a significant role in treatment of massive hemoptysis, which is rare, but fatal if occurs in patients with IPA. Gorelik et al 2000, the British infection J society
PCR
– There is a considerable clinical value of PCR assay for confirming and improving the diagnosis of IPA in high-risk patients. Buchheidt et al British J of Hem 2002
– Aspergillus PCR on whole blood samples is highly sensitive for the detection of IPA and correlated to tissue invasion Raad et al American cancer society 2002
– PCR was sensitive for the diagnosis of IPA Kami et al clinical infec dis 2001
| SENSITIVITY | SPECIFICITY | |
| PCR | 79 % | 92% |
| ELISA | 58% | 97% |
| BDG | 67% | 84% |
Aspergillus mitochondrial DNA PCR-ELISA on BAL is useful in early diagnosis for IPA in neutropenic patients, Jones et al J clin path 98.
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