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Aspergillosis

Aspergillosis is the name of a group of conditions caused by a fungal mould called aspergillus.

Aspergillosis is the name of a group of conditions caused by a fungal mould called aspergillus.

It usually affects the respiratory system (windpipe, sinuses and lungs), but it can spread to anywhere in the body.

Depending on a number of factors, the symptoms of aspergillosis can vary in severity from mild wheezing to coughing up blood. Someone with a weakened immune system is at greater risk of being more severely affected.

What causes aspergillosis?

Aspergillosis is caused by breathing in small spores of aspergillus mould. Most people's immune systems will quickly isolate and destroy the mould before it can spread to their lungs.

However, a person with damaged lungs or a weakened immune system is more likely to develop aspergillosis after breathing in aspergillus spores.

Aspergillosis isn't contagious and can't be passed between people or animals.

Read more about the causes of aspergillosis.

When to see your GP

You should contact your GP immediately if you have symptoms that suggest you may have an infection, such as a fever or persistent coughing, and:

  • you're taking medication to suppress your immune system (immunosuppressants) after an organ or bone marrow transplant
  • you have a condition known to weaken the immune system, such as cancer

Your GP will check your symptoms and carry out a physical examination. Further tests will be needed to confirm a diagnosis if they think you may have aspergillosis. The type of tests you'll have will depend on the type of aspergillosis suspected.

Read more about diagnosing aspergillosis.

Types of aspergillosis

There are four main types of aspergillosis in the lungs. They are:

  • allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS) 
  • chronic pulmonary aspergillosis (CPA), including aspergilloma
  • invasive pulmonary aspergillosis (IPA) 
  • aspergillus bronchitis and tracheobronchitis

There are also a number of other types of aspergillosis, including aspergillus sinusitis, postoperative aspergillosis, and fungal keratitis. This topic concentrates on the four main types that affect the lungs.

Allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitisation

Allergic bronchopulmonary aspergillosis (ABPA) is caused by an allergic reaction to the spores of the aspergillus mould. It's the mildest form of aspergillosis.

ABPA usually affects people with asthma or other respiratory disorders, such as cystic fibrosis, tuberculosis or chronic obstructive pulmonary disorder (COPD).

Globally, ABPA affects around 2.5% of adults with asthma (4.8 million out of 193 million). It's estimated that severe asthma with fungal sensitisation (SAFS) affects 3.25 to 13 million adults worldwide, depending on the frequency of severe asthma (5 to 20% of all people with asthma).

Both ABPA and SAFS can be treated with antifungal medication.

Chronic pulmonary aspergillosis

Chronic pulmonary aspergillosis (CPA) is a long-term lung infection. Aspergillus fumigatus is usually the species of fungal mould responsible. Most people with CPA have an underlying lung condition.

If you have CPA, you may also have an aspergilloma (a fungal ball found in a single lung cavity). Aspergillomas are common in people with cystic fibrosis or cavities (spaces) in their lungs. Coughing up blood is a common symptom.

If there are cavities in the lungs but no fungal ball, the condition is known as chronic cavitary pulmonary aspergillosis.

Pulmonary aspergillosis can cause the lungs to become permanently scarred if it isn't treated.

Invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis (IPA) usually only affects people with lowered immunity, such as those who have received a bone marrow transplant or cancer treatment, or those with HIV or AIDS. It's the most serious type of aspergillosis.

If you have IPA, it's likely you will have a raised temperature (slightly increased, but not necessarily to the level of a fever) as well as lung symptoms, such as a cough, chest pain or breathlessness, that can't be treated with normal antibiotics.

In people with a severely weakened immune system, the fungus can spread through the bloodstream from the lungs to the brain, eyes, heart or kidneys. This is very serious and can be life threatening if it's not diagnosed and treated quickly. Hospitalisation and treatment with antifungal medication will be needed.

IPA is estimated to occur in:

  • 5 to 13% of people who've had a bone marrow transplant
  • 5 to 25% of people who've had a heart or lung transplant
  • 10 to 20% of people who've had high-dose radiotherapy or chemotherapy for leukaemia (cancer of the blood cells)

Aspergillus bronchitis and tracheobronchitis

Aspergillus bronchitis and tracheobronchitis is a rarer type of aspergillosis infection that affects the tracheobronchial tree (the structure that forms the airways that supply air to the lungs, made up of the trachea, bronchi and bronchioles).

Some experts have suggested that the term "tracheobronchitis" should also cover cases where the trachea or bronchi are inflamed, where there is excess mucus production and where aspergillus is the only source of infection.

However, because of the large number of possible clinical features in such cases, there's currently no definitive classification of this type of aspergillosis.

Treating aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is usually treated with steroid medications to prevent an allergic response. However, if ABPA reoccurs, a long-term course of steroids may be required as well as itraconazole antifungal therapy.

SAFS also improves with steroids and antifungal therapy, although omalizumab may also be helpful.

Chronic pulmonary aspergillosis and aspergilloma, and aspergillus bronchitis and tracheobronchitis, can be treated with antifungal medications taken for long periods. In some cases, surgery may be needed to remove the infection from the lungs.

Invasive pulmonary aspergillosis (IPA) can also be treated with intravenous antifungal medication, but it's difficult to treat. In most people, voriconazole is the best initial therapy.

The infection can spread very quickly, and someone who develops IPA is usually already very ill. Around 50% of people don't respond to treatment and die from the condition.

Read more about how aspergillosis is treated.

Preventing aspergillosis

It's almost impossible to avoid the aspergillus fungus completely, but there are precautions you can take to prevent aspergillosis.

If you have asthma, a weakened immune system, or a history of lung disease, you should avoid places where the aspergillus fungus is likely to be, such as:

  • compost heaps
  • grain stores
  • rotting vegetation
  • piles of dead leaves
  • marshland and bogs
  • forests

If you have a weakened immune system, you may also be advised to take extra precautions, such as wearing a face mask and taking antifungal medicines. This may be the case if you're having chemotherapy, you've recently had an organ transplant, or you're taking high doses of corticosteroid medication.

Read more about preventing aspergillosis.

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Aspergillosis

The symptoms of aspergillosis vary depending on the condition's type and the affected area of the body affected.

The symptoms of aspergillosis vary depending on the type of condition and the area of the body that's affected.

Allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS)

The symptoms of allergic bronchopulmonary aspergillosis (ABPA) include:

  • shortness of breath 
  • wheezing
  • fatigue (extreme tiredness)
  • cough that brings up mucus or plugs (solid lumps of mucus)
  • generally feeling unwell

If you have asthma, your usual symptoms may become more difficult to control with medication.

Symptoms of severe asthma with fungal sensitisation (SAFS) include:

  • persistent wheezing 
  • severe breathlessness
  • persistent nasal symptoms

Unlike ABPA, someone with SAFS doesn't produce thick mucus, but there may be some mucus present in their airways. Persistent long-term asthma symptoms that can't be controlled with medication are also a common characteristic of SAFS.

Chronic pulmonary aspergillosis (CPA), including aspergilloma

In the initial stages, someone with chronic pulmonary aspergillosis (CPA) may not have any symptoms. However, they may later experience the following symptoms:

  • weight loss
  • breathlessness
  • a persistent cough
  • coughing up blood
  • fatigue (extreme tiredness)

Coughing up blood is the most common symptom of aspergilloma. Other likely symptoms include a cough and a mild fever.

Invasive pulmonary aspergillosis (IPA)

The symptoms of invasive pulmonary aspergillosis (IPA) can vary depending on where in the body the infection spreads. Symptoms include:

  • a raised temperature (increased but not necessarily to the level of a fever) despite taking antibiotics
  • coughing up blood
  • breathlessness
  • chest pain or discomfort
  • fatigue

Aspergillus bronchitis and tracheobronchitis

Aspergillus bronchitis and tracheobronchitis can sometimes affect people with bronchiectasis.

Bronchiectasis is a long-term condition where the lung's airways become abnormally widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection.

Common symptoms of bronchiectasis include a persistent cough that usually brings up phlegm, and breathlessness.

People with cystic fibrosis are also at risk of developing aspergillus bronchitis and tracheobronchitis, as they have reduced lung function. Recurrent chest infections and the production of very thick mucus that causes breathing difficulties are common.

When to seek medical advice

Contact your GP, care team or transplant team immediately if you develop symptoms that suggest you may have aspergillosis, such as persistent coughing or a fever, and:

  • you're taking immunosuppressants after an organ or bone marrow transplant
  • you have a condition known to weaken the immune system, such as cancer

You should always contact your GP if you:

  • cough up blood
  • have unexplained weight loss
  • have a persistent cough and high temperature
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Aspergillosis

Aspergillosis is caused by breathing in small spores of aspergillus mould.

Aspergillosis is caused by breathing in small spores of aspergillus mould.

In most healthy people, their immune system is able to quickly isolate and destroy the mould before it spreads to their lungs.

However, if a person with damaged lungs or a weakened immune system breathes in the spores, aspergillosis is more likely to develop.

Aspergillosis isn't contagious, which means that it can't be passed between people or animals.

Aspergillus mould

The aspergillus mould that causes aspergillosis is found in all countries and in many different environments. This makes it difficult to avoid.

Aspergillus mould can be found in:

  • rotting leaves
  • compost
  • plants
  • trees
  • crops

The mould can also grow inside buildings and is sometimes found in:

  • air conditioning systems
  • heating systems
  • insulation material
  • carpets
  • pillows and bedding 
  • dust
  • household plants
  • ground pepper and spices

There have even been cases where aspergillus mould has been found growing inside computers.

If you have damaged lungs or a weakened immune system, you may be advised to take extra precautions, such as using a face mask or taking antifungal medication.

Your immune system may be weakened if you're having chemotherapy to treat cancer, or if you're taking immunosuppressant medication or high doses of corticosteroids

Read more about preventing aspergillosis.

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Aspergillosis

You will have a physical examination and your symptoms will be checked. If aspergillosis is suspected, you'll have further tests to confirm a diagnosis.

Your GP or specialist will check your symptoms and carry out a physical examination.

If they think you may have aspergillosis, you'll need further tests to confirm a diagnosis.

Allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS)

If allergic bronchopulmonary aspergillosis (ABPA) is suspected, you'll have a skin prick test. You may be referred to a specialist at an allergy clinic for the test.

Your skin will be pricked with a needle that contains a small amount of aspergillus mould. If you're allergic, the area of skin where the needle was inserted will come up in a hard red bump.

Blood tests are also used to check for immunoglobulin E (IgE) antibodies, which will be produced by your immune system if you're allergic to the aspergillus mould. Antibodies are special proteins that help fight infections and are markers of allergy.

You may also have a computerised tomography (CT) scan to check whether there's a build-up of mucus in your lungs or bronchiectasis, which is common in ABPA.

As well as having severe asthma, someone with severe asthma with fungal sensitisation (SAFS) will also be sensitised (allergic) to one or more types of fungi. As with ABPA, this can be diagnosed using a skin prick test, where your skin is pricked with a tiny amount of the suspected allergen to see if there's a reaction. Most people with SAFS will be sensitised to one or more types of fungi.

Chronic pulmonary aspergillosis (CPA), including aspergilloma

If chronic pulmonary aspergillosis (CPA) is suspected, you'll have a chest X-ray. A diagnosis will also be based on symptoms such as weight loss, fatigue, a persistent cough and breathlessness that have lasted for more than three months.

If aspergilloma (a fungal ball) is suspected, you'll probably be referred for a CT scan as well as a chest X-ray. The scan will be used to check for an aspergilloma, which can show up as a dark mass.

A blood test may also be used to check for aspergillus (IgG) antibodies and a sample of your mucus may be tested for fungal growth. Occasionally, a biopsy (small tissue sample) may also be taken if a mass is found in a lung cavity.

Invasive pulmonary aspergillosis (IPA)

Invasive pulmonary aspergillosis (IPA) is diagnosed in the same way as CPA, using a combination of CT scans, blood tests, mucus tests, and possibly a bronchoscopy or biopsy.

It's important that all of the tests are carried out within 72 hours and treatment is started as soon as possible.

Aspergillus bronchitis and tracheobronchitis

A bronchoscopy with bronchial biopsy is recommended to help diagnose aspergillus bronchitis and tracheobronchitis.

Aspergillus or mucus must be present in the airways for a diagnosis of aspergillus bronchitis to be made. Sometimes a sensitive molecular test is needed to confirm this.

A bronchoscopy is a procedure where a bronchoscope (a long, flexible tube with a camera at the end) is inserted into the airways, usually through the nose or mouth. During the examination a small piece of affected tissue is removed (biopsy) for testing in a laboratory.

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Aspergillosis

Treatment for aspergillosis varies depending on the condition's type and severity. Antifungal medication is often prescribed. Surgery may be needed in severe cases.

Treatment for aspergillosis varies depending on the condition's type and severity.

Steroid or antifungal medications are often prescribed. In severe cases, surgery to remove the infected piece of lung tissue may be needed.

Allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS)

Allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS) are often treated using corticosteroid tablets (oral corticosteroids) and antifungal medication.

Corticosteroids suppress the immune system, which helps prevent the allergic reaction associated with ABPA and SAFS.

Most people need a two- to six-month course of oral corticosteroids. The dose will be gradually reduced over time before treatment is stopped.

Side effects of long-term corticosteroid use include weight gain, diabetes and bruising easily. While taking corticosteroids you'll also need regular appointments to check for high blood pressure (hypertension) and osteoporosis (brittle bones).

Itraconazole is an antifungal medicine often used to treat ABPA and SAFS. However, you should be aware that itraconazole interacts with some types of inhaled steroid preparations, reducing their effectiveness in up to 50% of people.

The drug interacts with dexamethasone, methylprednisolone, budesonide and possibly fluticasone. It doesn't interact with prednisolone or prednisone.

You can read more about interactions between antifungals and other medicines on The Aspergillus Website.

Chronic pulmonary aspergillosis (CPA), including aspergilloma

Itraconazole and voriconazole are the two antifungals used to treat chronic pulmonary aspergillosis (CPA).

How long you'll need to take these medications for will depend on how well your symptoms react to them.

Common side effects for itraconazole include:

  • high blood pressure (hypertension)
  • swollen ankles (oedema)
  • nausea
  • low potassium
  • fatigue
  • loss of libido (sex drive) or impotence
  • peripheral neuropathy (damage to the peripheral nervous system)

Rarer side effects include:

Aspergilloma doesn't always need to be treated. If your doctor thinks treatment is needed, itraconazole may be prescribed. 

If itraconazole is ineffective or has bad side effects, voriconazole may be used instead.

In some cases, surgically removing the affected piece of lung tissue may be an option.

Invasive pulmonary aspergillosis (IPA)

Voriconazole is a powerful antifungal medication, and is the best method of treatment for invasive pulmonary aspergillosis (IPA).

If you're diagnosed with IPA, it's likely that you'll be admitted to hospital so that you can be carefully monitored while you're on voriconazole. You may be given assistance with your breathing if you need it.

Common side effects of voriconazole include:

  • dry eyes
  • sore lips
  • skin photosensitivity (sensitivity to light)
  • peripheral neuropathy – damage to the peripheral nervous system (particularly with an increased dose)
  • impaired thinking and imbalance

Nausea, vomiting and stomach pains are rarer side effects of voriconazole.

If you also have a weakened immune system, you may be given additional treatment to help strengthen it.

This includes a type of medication known as colony-stimulating factors (CSFs). CSFs encourage your bone marrow to produce more white blood cells, which fight infection.

A medication called interferon gamma can also be used to boost the immune system. Interferon gamma is a genetically engineered version of a protein that the immune system uses to fight off infection.

The most common side effects of CSFs and interferon gamma are flu-like symptoms, such as:

  • a high temperature of 38°C (100.4°F) or above
  • chills
  • joint and muscle pain
  • headaches
  • nausea

Surgery

Surgery may be recommended in cases of CPA and aspergilloma that don't respond to antifungal treatment, or if the coughing up of blood is thought to be life threatening.

Extensive coughing up of blood can cause the lung tissue to become filled with blood, leading to suffocation.

Surgical resection

Surgical resection of the lung, where the infected piece of lung tissue is removed, is one treatment option in severe cases of CPA, aspergilloma and IPA.

There are three types of surgical resection that can be used, depending on the extent of the infection. These are:

  • wedge resection – where a small piece of lung is removed
  • lobectomy – where the top or bottom half of the lung (known as a "lobe") is removed
  • pneumonectomy – where the entire lung is removed

Many people who have a surgical resection are worried that they'll be unable to breathe properly afterwards, but it's possible to breathe with just one lung.

Bronchial artery embolisation (BAE)

Bronchial artery embolisation (BAE) is often used to treat coughing up of blood that is life threatening.

Coughing up blood is caused when one of the bronchial arteries (the major blood vessels in the lungs) is weakened by infection.

The weakened artery then ruptures (splits), releasing blood. BAE is used to block the flow of blood out of the artery.

During BAE, a small, flexible tube called a catheter will be guided into your lungs. A CT scanner is usually used to guide the catheter to the exact site of the rupture.

A jelly-like solution is then passed down the catheter, which blocks the site of the rupture and prevents further bleeding.

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Aspergillosis

It's virtually impossible to avoid the aspergillus fungus completely, but you can take precautions to prevent aspergillosis.

It's virtually impossible to avoid the aspergillus fungus completely, but you can take precautions to prevent aspergillosis.

Avoiding exposure

The main way to prevent aspergillosis is to avoid being exposed to the aspergillus fungus.

You should avoid places where the aspergillus fungus is likely to be found if you have asthma, a weakened immune system or a history of lung disease. For example, it can be found in:

  • compost heaps
  • grain stores
  • rotting vegetation
  • piles of dead leaves
  • marshland and bogs
  • forests

The harmful effects of the fungus can be reduced in buildings through dust control and good ventilation – for example, by opening windows. This is particularly important if construction or renovation work is being carried out.

Keeping the room disinfected, maintaining room temperature and ensuring adequate air flow are all useful ways of preventing an aspergillosis infection.

It's also important to clean skin injuries thoroughly using soap and water, particularly if the injury has been exposed to soil or dust.

Extra precautions

If you have a weakened immune system, your GP or specialist may recommend that you take extra precautions, such as:

  • wearing a face mask when near dusty environments, such as construction sites
  • avoiding activities that involve close contact with soil and dust, such as gardening
  • using air purifiers
  • taking antifungal medication

Your immune system may be weak if:

Some people are given antifungal therapy to prevent fungal infections, particularly those with leukaemia (cancer of the blood) and those who've had a lung or bone marrow transplant. 

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