Chronic pulmonary aspergillosis includes several disease manifestations, including aspergilloma, chronic cavitary pulmonary aspergillosis, chronic fibrosing pulmonary aspergillosis, and chronic necrotizing aspergillosis. Duration of disease longer than three months distinguishes chronic pulmonary aspergillosis from acute and subacute pulmonary aspergillosis.
●Chronic pulmonary aspergillosis represents a spectrum of disease; the risks and benefits of medical and surgical therapy vary with the manifestations of disease and the patient's pulmonary status, and, thus, the approach to therapy must be individualized.
●For patients with a simple aspergilloma, we suggest surgical resection for patients who are symptomatic, particularly for those with hemoptysis, in order to prevent or treat potentially life-threatening hemoptysis (Grade 2C). We suggest antifungal therapy for patients who have progressive radiographic findings and/or symptoms and who are unable to undergo surgery. We also suggest antifungal agents for adjunctive therapy following surgical resection, particularly if there is concern about concomitant tissue invasion by Aspergillus spp (Grade 2C).
●In patients with moderate or severe hemoptysis who are too ill to undergo surgery or have extensive disease, embolization may be appropriate.
●We suggest not treating asymptomatic patients who have a simple aspergilloma or an Aspergillus nodule that is radiographically stable (Grade 2C).
●For patients with chronic cavitary pulmonary aspergillosis or chronic fibrosing pulmonary aspergillosis, we suggest voriconazole or itraconazole initially (Grade 2C). Voriconazole should be administered as 400 mg orally twice daily for the first day followed by 200 mg twice daily. Itraconazole should be administered as 200 mg orally twice daily. Serum drug concentrations should be monitored initially to optimize dose and preparation. Lifelong therapy is often required. For those who are severely ill, intravenous therapy may be needed initially. Voriconazole (6 mg/kg twice daily for the first day followed by 4 mg/kg twice daily thereafter), micafungin (150 mg daily), or amphotericin B (3 to 5 mg/kg daily for a lipid formulation or 1 mg/kg daily for the deoxycholate formulation) can be used.
●For patients with chronic necrotizing pulmonary aspergillosis, which is more aggressive in its course than chronic cavitary pulmonary aspergillosis, we recommend voriconazole (400 mg orally twice daily for the first day followed by 200 mg twice daily) (Grade 1B). Posaconazole (300 mg every 12 hours on the first day, then 300 mg once daily), amphotericin B, or itraconazole can be used as alternatives if the patient cannot take voriconazole.