Chronic necrotizing pulmonary aspergillosis: approach to management

To describe our experience with 6 patients and to review the current literature to update the approach to the diagnosis and treatment of chronic necrotizing pulmonary aspergillosis.

Patient reports and MEDLINE review of English-language literature published after 1980.

Chronic necrotizing pulmonary aspergillosis (CNPA) is a subacute infection most commonly seen in patients with altered local defense from preexisting pulmonary disease or in patients with risk factors that alter systemic immune status. Delays in diagnosis are common. Although initial reports advocated intravenous amphotericin B, itraconazole has emerged as a better initial therapy because of its documented efficacy and minimal toxicity. The dose and duration of therapy should be based on clinical response. In patients who do not respond to medical therapy, pulmonary resection can be considered, but postoperative morbidity is high. Recurrent or relapsing infections occur; chronic maintenance therapy with itraconazole can be considered in patients with residual parenchymal scarring. A wide range of mortality rates has been reported for CNPA. Outcome is most likely influenced by severity of comorbid conditions, extent of underlying pulmonary disease, delays in diagnosis, and initiation of effective therapy.