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Christine Ahn MD
Carl Allen DDS, MSD
Brandon Ayres MD
Howard P. Baden MD
Robert Baran MD
Keira Barr MD
Gregory J. Basura MD, Ph.D
Donald Belsito MD
Jeffrey D. Bernhard MD
Jesse Berry MD
Victor Blanco MD
Benjamin R. Bohaty MD
William Bonnez MD
Sarah Brenner MD
Robert A. Briggaman MD
Robert Brodell MD
Roman Bronfenbrener MD
Walter Brooks MD
William Buckley MD
Philip Bulterys MD, PhD (candidate)
Susan Burgin MD
Sonya Burton MD
Sean P. Bush MD, FACEP
Jeffrey Callen MD
Scott Camazine MD
Michael Cardwell
Shelley D. Cathcart MD
Robert Chalmers MD, MRCP, FRCP
Chia-Yu Chu MD, PhD
Flavio Ciferri MD
Maria Rosa Cordisco MD
Noah Craft MD, PhD
John T. Crissey MD
Harold E. Cross MD, PhD
Charles E. Crutchfield III MD
Adriana Cruz MD
Donna Culton MD, PhD
Bart J. Currie MBBS, FRACP, DTM&H
Chicky Dadlani MD
Alexander Dane DO
C. Ralph Daniel III MD
Thomas Darling MD, PhD
William Delaney MD
Damian P. DiCostanzo MD
Ncoza Dlova MD
James Earls MD
Libby Edwards MD
Melissa K. Egge MD
Charles N. Ellis MD
Rachel Ellis MD
David Elpern MD
Nancy Esterly MD
Stephen Estes MD
E. Dale Everett MD
Janet Fairley MD
David Feingold MD
Jennifer J. Findeis-Hosey MD
Benjamin Fisher MD
Henry Foong MBBS, FRCP
David Foster MD, MPH
Brian D. Foy PhD
Michael Franzblau MD
Vincent Fulginiti MD
Sunir J. Garg MD, FACS
Kevin J. Geary MD
Lowell Goldsmith MD, MPH
Sethuraman Gomathy MD
Bernardo Gontijo MD, PhD
Kenneth Greer MD
Kenneth G. Gross MD
Alan Gruber MD
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Akshya Gupta MD
Vidal Haddad MSC, PhD, MD
Edward Halperin MD, MA
Ronald Hansen MD
John Harvey
Rizwan Hassan MD
Michael Hawke MD
Jason E. Hawkes MD
Peter W. Heald MD
David G. Hicks MD
Sarah Hocker DO
Ryan J. Hoefen MD, PhD
Li-Yang Hsu MD
William Huang MD
Sanjana Iyengar MD
Alvin H. Jacobs MD
Saagar Jadeja MD
Shahbaz A. Janjua MD
Joshua J. Jarvis MD
Kit Johnson
Zachary John Jones MD
Robert Kalb MD
A. Paul Kelly MD
Henry Kempe MD
Loren Ketai MD
Sidney Klaus MD
Ashwin Kosambia MD
Jessica A. Kozel MD
Carl Krucke
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Joseph Lam MD
Alfred T. Lane MD
Edith Lederman MD
Nahyoung Grace Lee MD
Pedro Legua MD, PhD
Robert Levin MD
Bethany Lewis MD
Sue Lewis-Jones FRCP, FRCPCH
Taisheng Li MD
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Shari Lipner MD, PhD
Adam Lipworth MD
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Mark Malek MD, MPH
Jere Mammino DO
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J. Martin Rodriguez, MD, FACP
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Organizations
Am. Journal of Trop. Med & Hygiene
Armed Forces Pest Management Board
Blackwell Publishing
Bugwood Network
Centers For Disease Control and Prevention
Centro Internacional de Entrenamiento e Investigaciones Mèdicas (CIDEIM)
Dermatology Online Journal
East Carolina University (ECU), Division of Dermatology
Aspergillus, a hyaline mold, is found ubiquitously worldwide in decaying vegetation, soil, water, food, and plants. Inhalation of Aspergillus conidia into the lungs is the most common mode of acquisition. The varied pulmonary manifestations of infection depend to a large degree on the immune status of the host. They range from colonization leading to tracheobronchitis or a fungus ball to invasive disease in immunocompromised patients. There also can be an allergic response as with allergic bronchopulmonary aspergillosis (ABPA).
Aspergillus tracheobronchitis, which occurs in lung transplant recipients, can be asymptomatic but may cause fever, cough, wheezing, and hemoptysis.
An aspergilloma, or fungus ball, is a solid clump of mold growing in a pre-existing pulmonary cavity. This is most common in an immunocompetent host. It presents clinically with cough and hemoptysis.
ABPA syndrome is characterized by transient pulmonary infiltrates, and exacerbation of dyspnea, wheezing, and cough in chronic asthmatics and patients with cystic fibrosis.
Patients with prolonged and profound neutropenia (absolute neutrophil count <100/mm3), those undergoing hematopoietic stem cell transplantation (HSCT), patients on chronic high dose corticosteroids, patients with chronic granulomatous disease, solid organ transplant recipients (especially lung), and those on newer immunosuppressives such as TNF-alpha antagonists or T-cell ablative agents (alemtuzumab, antithymocyte globulins) are at risk for invasive disease. This most commonly begins in the lung, and dissemination can occur by hematogenous route or as a result of local extension. Dissemination can lead to central nervous system, liver, spleen, heart, bone, and skin involvement. Invasive pulmonary aspergillosis often presents with asymptomatic fever and incidental radiographic findings, but can also present with dry cough, dyspnea, pleuritic chest pain, and fever. These symptoms can resemble those of pulmonary embolism, reflecting the angio-invasive nature of the disease.
A locally invasive or semi-invasive form of the disease that lacks vascular invasion or distant dissemination is also recognized. This is an indolent process that develops over months or years, hence its other name, chronic necrotizing aspergillosis.
Cutaneous aspergillosis begins as red papules that form pustules. These pustules ulcerate and leave a central eschar evocative of the diagnosis.
Codes
ICD10CM: B44.9 – Aspergillosis, unspecified
SNOMEDCT: 65553006 – Aspergillosis
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
Other invasive molds like Fusarium and Scedosporium are impossible to distinguish based on morphology, and diagnosis requires a positive culture.
The molds belonging to the Mucorales order (especially Rhizopus), which cause mucormycosis, may present with similar clinical syndromes but are usually distinguishable from Aspergillus based on morphology. Mucorales fungi are broad, nonseptate hyphae with branches at right angles.
In immunocompromised patients with pulmonary nodules, there are many infectious and noninfectious etiologies that are possible (an infectious diseases consultation is recommended). Some organisms to consider include Nocardia species, mycobacterial species, Legionella species, cryptococcal infection, and the endemic fungi. In some cases, Pneumocystis jirovecii and even viral pathogens can present with nodular lung disease. Septic emboli are possible (especially in patients who may have indwelling central venous catheters). Noninfectious causes of nodular lung disease including malignancy should also be considered.
Differential diagnosis for cutaneous presentations:
Noninfectious causes of nodular skin lesions, including Sweet syndrome
Best Tests
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Management Pearls
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.
