Infectious Diseases

Answer 3 Perform a CT scan of the chest and possibly a bronchoalveolar lavage/open lung biopsy. Invasive pulmonary aspergillosis (IPA) is the most likely diagnosis in this patient. IPA is encountered in patients with prolonged neutropenia, those undergoing bone marrow or solid organ transplantation, and those treated with high-dose corticosteroids. Multiple diagnostic approaches should be used rapidly if invasive aspergillosis is suspected. High-resolution CT scans of the chest and sinuses can play a role in early diagnosis, particularly in patients with normal chest radiographs; bronchoalveolar lavage/open lung biopsy may also be helpful. A definitive diagnosis rests upon demonstration of septate, hyaline branching hyphae in lung tissue with a concurrent positive culture of a respiratory specimen for Aspergillus species. The mortality rate for IPA is extremely high. Amphotericin B (conventional and lipid formulations) and itraconazole are the antifungal agents approved for the treatment of this fatal disease. Fluconazole has no role in the treatment of aspergillosis. Decreasing the intensity of immunosuppression can be helpful. Pulmonary embolism is less likely, given the subacute onset of cough, fever, bilateral crackles on lung examination, and nodular appearing infiltrates. Pneumocystis carinii pneumonia (PCP) is occasionally seen in this subgroup of patients on corticosteroids; with the routine use of prophylaxis with trimethoprim-sulfamethoxazole, PCP is uncommon. Also, the chest radiographs in patients with PCP usually show interstitial infiltrates; nodules and cavitation are rare. Click here to return to the questions

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