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Chronic necrotizing pulmonary aspergillosis: approach to management
J L Saraceno1, D T Phelps, T J Ferro
1Department of Medicine, Samuel S. Stratton VA Medical Center, the Albany Medical College, NY 12208, USA.
Objective:
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.
Design:
Patient reports and MEDLINE review of English-language literature published after 1980.
Results:
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.
Insights
Chronic necrotizing pulmonary aspergillosis (CNPA) is a fungal lung infection. Itraconazole is now preferred over amphotericin B for initial treatment due to better efficacy and fewer side effects.
Area of Science:
- Pulmonology
- Infectious Diseases
- Mycology
Background:
- Chronic necrotizing pulmonary aspergillosis (CNPA) is a subacute fungal infection.
- It primarily affects individuals with compromised local defenses or systemic immune alterations.
Observation:
- Diagnosis of CNPA is frequently delayed.
- Initial treatment often involved intravenous amphotericin B.
Findings:
- Itraconazole has emerged as a superior initial therapy for CNPA, offering documented efficacy and reduced toxicity compared to amphotericin B.
- Treatment duration and dosage should be tailored to the patient's clinical response.
- Pulmonary resection is an option for refractory cases, but carries significant postoperative risks.
- Recurrences are possible, and long-term itraconazole maintenance may benefit patients with residual lung scarring.
Implications:
- Optimal management of CNPA requires prompt diagnosis and effective antifungal therapy, with itraconazole as a preferred first-line agent.
- Patient outcomes are significantly influenced by the severity of underlying conditions and the timeliness of treatment initiation.
- Further research into long-term management strategies for CNPA is warranted.