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Aspergillosis conceals itself in more places than you think 

Aspergillus is a type of mould that causes a spectrum of conditions, known as aspergillosis, which can be life-long, progressive and debilitating. 3-5

Aspergillus pervades our surroundings and can be hiding in many places: 3,6

  • Soil 
  • Damp insulation
  • Bedding or behind sofas
  • In the corner of damp rooms 
  • Dust 
Exposure to this mould is generally unavoidable but does not cause harm in most individuals.5 However it can develop in those living with certain risk factors such as a weakened immune system or a pre-existing lung condition.7,8 Fortunately, finding the right treatment usually helps control symptoms - and early identification can improve treatment outcomes.1,4
Aspergillosis is easy to miss


Aspergillosis can masquerade as chest infections, lung cancer or unexplained structural lung disease, and can also worsen symptoms in asthma, COPD, and other lung conditions.1,2

Uncovering aspergillosis 

In primary care, you're more likely to encounter non-invasive types of aspergillosis, such as chronic pulmonary aspergillosis (CPA) and allergic bronchopulmonary aspergillosis (ABPA). The acute, invasive form affects patients who are severely immunocompromised, such as those living with cancer or having recently undergone a transplant. It has also emerged that patients being treated in the ICU are at risk of developing invasive aspergillosis, as well as those who are severly ill with influenza or COVID-19.1,3,8

Learn more about different types of aspergillosis in the drop-down boxes below. 
Note: symptoms and risk factors listed are not exhaustive.

Chronic pulmonary aspergillosis (CPA)
A chronic, progressive lung infection, with a spectrum of presentations that range from single aspergilloma to chronic cavitary or fibrosing forms of aspergillosis.8

Risk factors:8-12

  • Pulmonary tuberculosis 
  • Non-tuberculosis mycobacterial infection 
  • Sarcoidosis 
  • ABPA 
  • Surgically resected lung cancer
  • Pneumothorax with bulla formation 
  • COPD
Symptoms:8-12
  • Weight loss
  • Cough 
  • Shortness of breath 
  • Haemoptysis (coughing up blood) 
​​​​​
Allergic bronchopulmonary aspergillosis (ABPA)
A complex hypersensitivity response to invasive Aspergillus mould.13,14

Risk factors:13,14

  • Asthma 
  • Cystic fibrosis
Symptoms:13,14
  • Malaise
  • Cough 
  • Production of mucus plugs 
Aspergillus bronchitis 
A chronic, superficial infection of lower airways that typically occurs in patients who are not significantly immunocompromised.15,16

Risk factors:15,16

  • Underlying bronchiectasis 
  • Inhaled corticosteroids 
  • Cystic fibrosis
Symptoms:15,16
  • Cough producing purulent sputum 
  • Shortness of breath 
  • History of recurrent chest infections with limited or no response to therapy 
Aspergillus rhinosinusitis 
Can manifest as non-invasive or invasive. The non-invasive form includes fungal balls and allergic fungal rhinosinusitis, whereas the invasive form is usually defined by the presence of hyphae in mucosa, submucosa, bone, or blood vessels of the paranasal sinuses.17-21

Risk factors:17-21
Non-invasive

  • Diabetes
  • Corticosterioid use 
  • Allergic rhinitis 
Invasive
  • Those who are immunocompromised 
Symptoms:17-21
Non-invasive
  • Mucopurulent nasal discharge 
  • Nasal congestion 
  • Sinus pain 
  • Impaired sense of smell 
Invasive
  • Nasal congestion 
  • Fever
  • Sinus pain 
  • Epistaxis 
  • Facial numbness 
  • Diplopia 
  • Cough producing purulent sputum 
  • Shortness of breath 
  • History of recurrent chest infections with limited or no response to therapy 
Invasive pulmonary aspergillosis (IPA)  
Occurs when Aspergillus hyphae invade human blood vessels and spread across the body, causing disseminated infection, most commonly found in severely immunocompromised patients.22-31

Risk factors:22-31

  • Allogenic HSCT 
  • Solid organ transplant 
  • Treatment with B-cell immunosupressants
  • Prolonged neutropenia following chemotherapy 
In non-neutropenic hosts:
  • High-dose corticosteroid use 
  • Intensive care stay 
  • AIDS 
  • Lung cancer 
  • COPD hospitilisation 
  • Severe influenza 
  • COVID-19 
Symptoms:22-31
  • Fever 
  • Plueritic chest pain 
  • Haemoptysis 
  • Cough 
  • Shortness of breath 

CPA and ABPA are believed to affect more than 3 million and about 5 million people worldwide, respectively.32,33 But with difficulties and delays in diagnosis - made more challenging when aspergillosis is veiled in the shadows - the burden of aspergillosis could be even higher.32-34 It may be so well disguised, one estimate suggests that for every 12 people living with CPA, just one is recieving treatment.34,a

a. Low-confidence global estimate requiring additional study, made based on limited data available.34

A hidden threat 

With non-specific symptoms, chronic aspergillosis might disguise itself in your patients as other more common lung conditions.1,2 Or, if your patients are already living with a lung condition like asthma or COPD, aspergillosis could be shrouded by an apparent worsening of their existing ailment.30,31

Asthma

ABPA can mislead with wheezing and breathlessness, just like asthma exacerbations3,35

COPD

Hiding behind coughing and shortness of breath, CPA can lead clinicians to misdiagnose it as an exacerbation of COPD3,36

Lung cancer 

Persistent breathlessness, coughing up blood, and weight loss could mimic features suggestive of lung cancer3,37

Recurrent chest infection

Recurrent chest infection symptoms like mucus, cough and a high temperature can cover up aspergillosis as the real cause in at-risk patients3

Refer to rule it out 

Some people wait years for an aspergillosis diagnosis and appropriate treatment.1,39 Don't let this happen to your patients. You can help recognise the danger in disguise.

Consider your patients risk factors and medical history, in tandem with their symptoms. However unlikely it may seem, if you suspect aspergillosis is affecting your patient, refer them to secondary care as soon as possible. It's the only way to be sure.40

Be especially vigilant to your patients who return to you with ongoing, unresolved, or uncontrolled symptoms of what may appear to be a common lung condition, particuarly if this is despite several rounds of antibiotics or steroids. Could aspergillosis be undercover in your patients? 

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Reveal the threat 

When you refer your patient, a number of tests may be carried out to unveil or rule out aspergillosis: a diagnosis is usually made via imaging, blood tests, assays, sputum cultures, or tissue biopsy.40

If aspergillosis is revealed, the treatment and management they require will depend on the type your patient has. It could involve long-term antifungal medicines, steroid treatment or surgery to remove an aspergilloma.5

Learn more about diagnosis and managementLoading
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ABPA, allergic bronchopulmonary aspergillosis; COPD, chronic obstructive pulmonary disease; COVID-19, coronavirus disease-2019; CPA, chronic pulmonary aspergillosis; HSCT, haematopoietic stem cell transplantation; ICU, intensive care unit; IPA, invasive pulmonary aspergillosis.  

References: 

1. Bongomin F et al. J Fungi (Basel) 2020;6(2):75
2. American Lung Association. Aspergillosis Symptoms and Diagnosis. 2021. Available at: https://www.lung.org/lunghealth-diseases/lung-disease-lookup/aspergillosis/symptoms-diagnosis. Accessed June 2024
3. National Health Service (NHS). Aspergillosis. 2021. Available at: https://www.nhs.uk/conditions/aspergillosis/.  Accessed June 2024.
4. Aspergillosis Trust. Available at: https://www.aspergillosistrust.org/. Accessed June 2024.
5. Asthma and Lung UK. Aspergillosis. 2022. Available at: https://www.asthmaandlung.org.uk/conditions/ aspergillosis#what-is-aspergillosis. Accessed June 2024. 
6. O’Gorman CM. Fungal Biol Rev 2011;25(3):151–157.
7. Mousavi B et al. Curr Med Mycol 2016;2(1):36–42.
8. Kosmidis C, Denning DW. Thorax 2015;70(3):270–277.
9. Hayes GE & Novak-Frazer L. J Fungi (Basel) 2016;2(2):E18.
10. Denning DW et al. Clin Infect Dis 2003;37(Suppl 3):S265–S280.
11. Smith NL & Denning DW. Eur Respir J 2011;37(4):865–872.
12. Schweer KE et al. Mycoses 2014;57(5):257–270.
13. Greenberger PA. J Allergy Clin Immunol 2002;110(5):685–692.
14. Greenberger PA & Patterson R. J Allergy Clin Immunol 1988;81(4):646–650.
15. Chrdle A et al. Ann N Y Acad Sci 2012;1272:73–85.
16. Shoseyov D et al. Chest 2006;130(1):222–226.
17. Nicolai P et al. Laryngoscope 2009;119(11):2275–2279.
18. deShazo RD et al. Arch Otolaryngol Head Neck Surg 1997;123(11):1181–1188.
19. Trief D et al. Br J Ophthalmol 2016;100(2):184–188.
20.Talbot GH et al. Rev Infect Dis 1991;13(2):219–232.
21. Gillespie MB et al. Arch Otolaryngol Head Neck Surg 1998;124(5):520–526.
22. Ben-Ami R et al. Br J Haematol 2010;150(4):406–417.
23. De Pauw B et al. Clin Infect Dis 2008;46(12):1813–1821.
24. Marr KA et al. Clin Infect Dis 2002;34(7):909–917.
25. Singh N & Paterson DL. Clin Microbiol Rev 2005;18(1):44–69.
26. Denning DW. Clin Infect Dis 1998;26(4):781–803.
27. Trof RJ et al. Intensive Care Med 2007;33(10):1694–1703.
28. Schauwvlieghe AFAD et al. Lancet Respir Med 2018;6(10):782–792.
29. Ghez D et al. Blood 2018;131(17):1955–1959.
30. Feys S et al. J Fungi (Basel) 2021;7(12):1067.
31. Patel A et al. Emerg Infect Dis 2021;27(9):2349–2359.
32. Rønberg R et al. J Fungi (Basel) 2022;8(3):297.
33. Agarwal R et al. Indian J Med Res 2020;151(6):529–549.
34. Denning DW. Lancet Infect Dis 2024:S1473-3099(23)00692-8.
35. National Health Service (NHS). Asthma – symptoms. 2021.  Available at: https://www.nhs.uk/conditions/asthma/symptoms/. Accessed June 2024.
36. National Health Service (NHS). Chronic obstructive pulmonary disease – symptoms. 2023. Available at:  https://www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease-copd/symptoms/. Accessed June 2024.
37. National Health Service (NHS). Lung cancer – symptoms. 2022. Available at:  https://www.nhs.uk/conditions/lung-cancer/symptoms/. Accessed June 2024.
38. National Health Service (NHS). Chest infection – symptoms. 2023. Available at: https://www.nhs.uk/conditions/chest-infection/, Accessed June 2024.
39. Zeng Y et al. J Asthma Allergy 2022;15:53–62.
40. Centers for Disease Control and Prevention. Diagnosis and testing for aspergillosis. 2021. Available at:  https://www.cdc.gov/fungal/diseases/aspergillosis/diagnosis.html. Accessed May 2024.

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