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Chronic Pulmonary Aspergillosis Aspergillosi polmonare cronica

Number of patients with aspergillosis in EU. . Immune dysfunction. . . Frequency of aspergillosis. . Immune hyperactivity. . Frequency of aspergillosis. . . Subacute Invasive. AspergillomaChronic cavitaryChronic fibrosingLocally invasive. . . . After Casadevall

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Chronic Pulmonary Aspergillosis Aspergillosi polmonare cronica

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    1. Chronic Pulmonary Aspergillosis Aspergillosi polmonare cronica David W. Denning Director, National Aspergillosis Centre University Hospital South Manchester [Wythenshawe Hospital] The University of Manchester

    2. Number of patients with aspergillosis in EU

    3. Chronic pulmonary aspergillosis Single fungal ball or aspergilloma in a pre-existing cavity Exposure to individual Aspergillus spores or conidia is almost constant. If eradicated immediately, as is usual in normal people, no disease results. If colonisation occurs, it may be short or long term. The pattern of disease is mostly determined by the host group (see next slide), with probably a component of the inoculum size contributing to invasive disease. However chronic disease if usually seen in patients with apparently normal immune systems.Exposure to individual Aspergillus spores or conidia is almost constant. If eradicated immediately, as is usual in normal people, no disease results. If colonisation occurs, it may be short or long term. The pattern of disease is mostly determined by the host group (see next slide), with probably a component of the inoculum size contributing to invasive disease. However chronic disease if usually seen in patients with apparently normal immune systems.

    7. Aspergillus fumigatus occasionally other species

    8. Chronic pulmonary aspergillosis Single fungal ball or aspergilloma in a pre-existing cavity Exposure to individual Aspergillus spores or conidia is almost constant. If eradicated immediately, as is usual in normal people, no disease results. If colonisation occurs, it may be short or long term. The pattern of disease is mostly determined by the host group (see next slide), with probably a component of the inoculum size contributing to invasive disease. However chronic disease if usually seen in patients with apparently normal immune systems.Exposure to individual Aspergillus spores or conidia is almost constant. If eradicated immediately, as is usual in normal people, no disease results. If colonisation occurs, it may be short or long term. The pattern of disease is mostly determined by the host group (see next slide), with probably a component of the inoculum size contributing to invasive disease. However chronic disease if usually seen in patients with apparently normal immune systems.

    10. Underlying diseases in patients with CPA (%)

    18. Chronic pulmonary aspergillosis Single fungal ball or aspergilloma in a pre-existing cavity Exposure to individual Aspergillus spores or conidia is almost constant. If eradicated immediately, as is usual in normal people, no disease results. If colonisation occurs, it may be short or long term. The pattern of disease is mostly determined by the host group (see next slide), with probably a component of the inoculum size contributing to invasive disease. However chronic disease if usually seen in patients with apparently normal immune systems.Exposure to individual Aspergillus spores or conidia is almost constant. If eradicated immediately, as is usual in normal people, no disease results. If colonisation occurs, it may be short or long term. The pattern of disease is mostly determined by the host group (see next slide), with probably a component of the inoculum size contributing to invasive disease. However chronic disease if usually seen in patients with apparently normal immune systems.

    22. CPA and immune defects Mannose binding lectin Surfactant A2 Toll-like Receptor 4 Gamma IFN production Th2 dominated cytokine profile Poor responses to other common bacteria (Pneumococcus and Haemophilus)

    23. Outcome untreated

    27. CPA and coughing up blood (haemoptysis) Minor haemoptysis common Manageable with tranexamic acid orally Bronchial embolisation a good option, if vessel can be embolised & patient can lie flat for 2-3 hours

    28. CPA and surgery

    29. Survival from CPA

    30. Stopping treatment after good response ?

    33. Resistance ?

    34. 32 yr old from Malawi, on HAART Rx - haemoptysis - Aspergillus precipitin titre 16 CT scan shows 2 large cavities with aspergillomas, with additional lesions (October 2005)

    35. On HAART Rx, with low viral load, CD4 count >200 - New haemoptysis despite itraconazole - Aspergillus precipitin titre to 32 CXR & CT scan showed expansion of lower cavity

    36. Azole resistance in Manchester

    37. CPA treatment - principles Important defects in innate immunity so long term (i.e. life-long) antifungal treatment, if possible Itraconazole, voriconazole and posaconazole all effective, but adverse events Short or long courses of amphotericin B useful for patients with azole therapy failure Gamma IFN helpful in some cases Monitor for azole resistance

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