Invasive Aspergillosis Management

Clinical Presentation and Diagnosis

Invasive aspergillosis typically presents with fever unresponsive to broad-spectrum antibiotics in immunocompromised patients, with pulmonary involvement being the most common manifestation (56-59% of cases), according to the Infectious Diseases Society of America 1
The "halo sign" and "air-crescent sign" on CT are characteristic but not diagnostic, as noted by the European Society of Clinical Microbiology and Infectious Diseases 2
High-resolution CT scan should be performed within 24 hours of clinical suspicion, combined with serum galactomannan testing (sensitivity 74%, specificity 85%) and bronchoscopy with bronchoalveolar lavage for culture and histopathology, as recommended by the American Thoracic Society 2

Voriconazole is the first-line treatment for invasive aspergillosis with superior efficacy and survival outcomes compared to other antifungal agents (A-I recommendation), according to the Infectious Diseases Society of America 3
The loading dose of voriconazole is 6 mg/kg IV every 12 hours for 1 day, and maintenance is 4 mg/kg IV every 12 hours OR 200 mg oral twice daily, as recommended by the European Society of Clinical Microbiology and Infectious Diseases 3
Alternative primary therapy includes liposomal amphotericin B (L-AMB) 3-5 mg/kg/day IV for patients intolerant to voriconazole, as noted by the American College of Clinical Pharmacy 3

For CNS aspergillosis, voriconazole is the primary recommendation (A-II), and surgical resection of accessible lesions should be strongly considered, according to the Infectious Diseases Society of America 5
For sinonasal aspergillosis, a combined medical and surgical approach is essential, with aggressive surgical debridement plus systemic antifungal therapy, as recommended by the American Academy of Otolaryngology 1, 6

Surgical intervention is the only independent predictor of survival and should be considered for lesions contiguous with great vessels or pericardium, hemoptysis from cavitary lesions, chest wall invasion, or single pulmonary lesion before intensive chemotherapy or HSCT, as noted by the Society of Critical Care Medicine 7
Immunomodulatory approaches (B-III) include G-CSF or GM-CSF for neutropenic patients not already receiving colony-stimulating factors, and IFN-γ for patients with chronic granulomatous disease, according to the Infectious Diseases Society of America 8