Aspergillosis overview: Difference between revisions
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{{Aspergillosis}} | {{Aspergillosis}} | ||
{{CMG}}; | {{CMG}} {{AE}} {{HL}}; {{YD}}; {{SSK}} | ||
==Overview== | ==Overview== | ||
''' | ''Aspergillosis'' is a heterogenous group of infectious diseases caused by the fungus ''Aspergillus'' (commonly ''A. fumigatus''). | ||
==Historical Perspective== | |||
''Aspergillus'' is an ancient mold that has first been described in animals before it was discovered to be also pathogenic in humans. The exact date of discovery of ''Aspergillus'' as a pathogenic organism is unknown. | |||
==Classification== | |||
Apergillosis may be classified according to the clinical syndrome it causes into allergic bronchopulmonary aspergillosis, allergic ''Aspergillus'' sinusitis, aspergilloma, chronic pulmonary aspergillosis, invasive aspergillosis, or cutaneous aspergillosis. | |||
==Pathophysiology== | |||
''Aspergillus'' is primarily transmitted to the human host by inhalation of airborne conidia, dust exposure during building renovation or construction, or contaminated biomedical devices. ''Aspergillus'' is not transmitted from one individual to another. The pathogenesis of aspergillosis varies according to the associated clinical syndrome. Allergic bronchopulmonary aspergillosis and allergic ''Aspergillus'' rhinosinusitis are thought to be caused by both type I and type III hypersensitivity responses. Aspergilloma, Chronic pulmonary aspergillosis, and invasive aspergillosis are directly related to the growth and expansion of the ''Aspergillus'' hyphae in the lungs while avoiding phagocytosis by host immune cells. Cutaneous aspergillosis may result either from direct access of the ''Aspergillus'' through a skin break (primary) or dissemination of the ''Aspergillus'' to the skin from a distant infected organ (secondary). | |||
==Causes== | |||
Aspergillosis is caused by the fungus ''Aspergillus'', commonly ''A. fumigatus''. ''Aspergillus'' is ubiquitous in the environment. | |||
==Differential Diagnosis== | |||
Aspergillosis must be differentiated from other diseases that cause [[fever]], [[chest pain]], [[dyspnea]], [[sinusitis]], [[Allergy symptoms|allergic symptoms]], and elevated [[IgE]] concentrations. Differential diagnosis includes other infections (fungi, bacteria, viruses, and parasites), non-infectious pulmonary diseases (such as [[asthma]], [[COPD]], [[interstitial lung disease]], [[bronchiectasis]], and [[lung tumor]]s), cardiac diseases (such as [[pericarditis]], [[endocarditis]], or [[myocarditis]]), facial diseases (such as [[Sinusitis|infectious sinusitis]], sinus tumor, or [[Polyp|nasal polyp]]s), systemic diseases (such as [[Job's syndrome|Hyper IgE syndrome]], [[Churg-Strauss syndrome]], [[Wegener's granulomatosis|granulomatosis with polyangiitis]], [[Goodpasture's syndrome]]), congenital diseases (such as [[cystic fibrosis]] or [[ciliary dyskinesia]]), transplant-related complications (such as [[GVHD]]), diseases with cutaneous manifestations (such as [[eczema]], [[scabies]], [[deep vein thrombosis]], [[cellulitis]]), and [[adverse drug reaction]]s. | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
The true incidence of aspergillosis is unknown since aspergillosis is not a reportable disease in the USA.<ref name="pmid23210682">{{cite journal| author=Denning DW, Pleuvry A, Cole DC| title=Global burden of allergic bronchopulmonary aspergillosis with asthma and its complication chronic pulmonary aspergillosis in adults. | journal=Med Mycol | year= 2013 | volume= 51 | issue= 4 | pages= 361-70 | pmid=23210682 | doi=10.3109/13693786.2012.738312 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23210682 }} </ref> The incidence of allergic bronchopulmonary aspergillosis is estimated to be 5 million worldwide.<ref name="pmid23210682">{{cite journal| author=Denning DW, Pleuvry A, Cole DC| title=Global burden of allergic bronchopulmonary aspergillosis with asthma and its complication chronic pulmonary aspergillosis in adults. | journal=Med Mycol | year= 2013 | volume= 51 | issue= 4 | pages= 361-70 | pmid=23210682 | doi=10.3109/13693786.2012.738312 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23210682 }} </ref> In contrast, invasive aspergillosis is much less common. The incidence is thought to be approximately 1 to 2 cases per 100,000 individuals. There is no gender predilection for the development of aspergillosis. Individuals of all age groups may be affected with aspergillosis. Elderly patients with long-standing chronic lung diseases and neonates are more likely to develop aspergillosis. With the advancement of immunosuppressive therapy and higher rates of transplantation, the incidence and detection of aspergillosis is increasing in developed countries.<ref name=CDC> Definition of Aspergillosis - Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/fungal/diseases/aspergillosis/statistics.html Accessed on Feb 8 2016</ref> | |||
== | |||
==Risk Factors== | ==Risk Factors== | ||
[[Immunocompromised status]] and history of prior lung disease are the most important risk factors in the development of aspergillosis. Other risk factors include history of [[asthma]], [[Burn|burn]] or [[surgical site wound]]s, and exposure to healthcare settings or construction sites. | |||
==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
Following transmission, the majority of patients do not develop any clinical manifestations. The incubation of ''Aspergillosis'' is highly dependent on the host immune factors. The incubation period may range from a few days to years, during which the host is asymptomatic. Among immunocompetent hosts, ''Aspergillosis'' may result in a localized pulmonary infection, allergic bronchopulmonary aspergillosis, or allergic ''Aspergillus'' sinusitis. Clinical manifestations may vary depending on the clinical syndrome. Among immunocompromised hosts, ''Aspergillosis'' progresses faster and has a more invasive course. If left untreated, aspergillosis in immunocompromised patients often progresses, and patients report worsening fever, chest pain, and hemoptysis. Invasive aspergillosis eventually invades non-pulmonary organs and becomes disseminated and life-threatening. | |||
==Diagnosis== | ==Diagnosis== | ||
===Diagnostic Criteria=== | |||
Diagnostic criteria are available for allergic bronchopulmonary aspergillosis and for allergic fungal rhinosinusitis. Major and minor diagnostic criteria are based on clinical, laboratory, and radiological findings. | |||
===History and Symptoms=== | ===History and Symptoms=== | ||
Symptoms of aspergillosis are dependent on the clinical syndrome and extent of disease invasion.<ref name="mayo">Aspergillosis. MAYO CLINIC (2015) http://www.mayoclinic.org/diseases-conditions/aspergillosis/basics/risk-factors/con-20030330 Accessed on February, 8 2016</ref><ref name="pmid21881144">{{cite journal| author=Kousha M, Tadi R, Soubani AO| title=Pulmonary aspergillosis: a clinical review. | journal=Eur Respir Rev | year= 2011 | volume= 20 | issue= 121 | pages= 156-74 | pmid=21881144 | doi=10.1183/09059180.00001011 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21881144 }} </ref> Patients with allergic bronchopulmonary aspergillosis or sinusitis have symptoms typical of asthma and sinusitis, respectively. Symptoms of invasive pulmonary aspergillosis include spiking [[fever]], [[pleuritic]] [[chest pain]], productive [[cough]], [[dyspnea]], and [[hemoptysis]]. Symptoms of chronic pulmonary aspergillosis include chronic [[fever]], [[weight loss]], [[Cough|productive cough]], and [[hemoptysis]]. | |||
===Physical Examination=== | |||
Invasive pulmonary aspergillosis patients often appear sick-looking, [[lethargic]], and [[fatigue|fatigued]]. In contrast, patients with pulmonary aspergilloma, allergic bronchopulmonary aspergillosis, or allergic sinusitis often appear healthy. Physical examination of patients with pulmonary or invasive aspergillosis is usually remarkable for [[Breath sound|decreased breath sounds]] with [[wheeze]]s, [[rales]], and [[Tactile fremitus|increased tactile fremitus]]. Physical examination of patients with cutaneous aspergillosis is usually remarkable for and single or multiple erythematous-to-violaceous [[cutaneous]] [[papule]]s, [[macule]]s, [[nodule]]s, or [[plaque]]s.<ref name="wiki">Aspergillosis. Wikipedia (2015) https://en.wikipedia.org/wiki/Aspergillosis Accessed on February, 8 2016</ref><ref name="pmid9774549">{{cite journal| author=van Burik JA, Colven R, Spach DH| title=Cutaneous aspergillosis. | journal=J Clin Microbiol | year= 1998 | volume= 36 | issue= 11 | pages= 3115-21 | pmid=9774549 | doi= | pmc=PMC105285 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9774549 }} </ref><ref name="pmid18303098">{{cite journal| author=Samarakoon P, Soubani A| title=Invasive pulmonary aspergillosis in patients with COPD: a report of five cases and systematic review of the literature. | journal=Chron Respir Dis | year= 2008 | volume= 5 | issue= 1 | pages= 19-27 | pmid=18303098 | doi=10.1177/1479972307085637 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18303098 }} </ref> | |||
===Laboratory Findings=== | |||
PCR is the method of choice for the diagnosis of aspergillosis. A single negative [[PCR]] result is sufficient to rule out aspergillosis, whereas two positive test results are required to confirm the diagnosis. Laboratory findings consistent with the diagnosis of aspergillosis include positive aspergillus antibody test, positive [[galactomannan]] test, elevated concentration of [[IgE]] [[immunoglobulin]], and positive culture from [[sputum]] or [[bronchoalveolar lavage]].<ref name="wiki">Aspergillosis. Wikipedia (2015) https://en.wikipedia.org/wiki/Aspergillosis#Diagnosis Accessed on February, 8 2016</ref><ref name="pmid21177400">{{cite journal| author=Cuenca-Estrella M, Bassetti M, Lass-Flörl C, Rácil Z, Richardson M, Rogers TR| title=Detection and investigation of invasive mould disease. | journal=J Antimicrob Chemother | year= 2011 | volume= 66 Suppl 1 | issue= | pages= i15-24 | pmid=21177400 | doi=10.1093/jac/dkq438 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21177400 }} </ref><ref name="pmid18384212">{{cite journal| author=Kradin RL, Mark EJ| title=The pathology of pulmonary disorders due to Aspergillus spp. | journal=Arch Pathol Lab Med | year= 2008 | volume= 132 | issue= 4 | pages= 606-14 | pmid=18384212 | doi=10.1043/1543-2165(2008)132[606:TPOPDD]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18384212 }} </ref> | |||
===Chest X Ray=== | ===Chest X Ray=== | ||
Chest X-ray may be helpful in the diagnosis of aspergillosis. Chest X-ray may be remarkable for recurrent pulmonary infiltrates in allergic bronchopulmonary aspergillosis. Findings on chest X-ray suggestive of aspergilloma include a well demarcated, round, soft tissue mass located inside an air space cavity of the [[lung]]s.<ref>{{cite journal | author = Curtis A, Smith G, Ravin C | title = Air crescent sign of invasive aspergillosis. | journal = Radiology | volume = 133 | issue = 1 | pages = 17-21 | year = 1979 | month = Oct | id = PMID 472287 | url=http://radiology.rsnajnls.org/cgi/content/abstract/133/1/17?ijkey=657da61e6546d66bd27550542bc4d25be2efe638&keytype2=tf_ipsecsha}}</ref><ref name="radio">Aspergilloma. Radiopaedia (2015) http://radiopaedia.org/articles/aspergilloma Accessed on February, 9 2016</ref> Multiple cavities with evidence of fibrosis are suggestive of chronic pulmonary aspergillosis, whereas focal nodules and infiltration are suggestive of invasive aspergillosis. | |||
===CT Scan=== | |||
Chest [[CT scan]] may be helpful in the diagnosis of aspergillosis. Findings on chest CT scan suggestive of aspergillosis include a well formed [[cavity]], a central [[soft tissue]] attenuating oval shaped, well circumscribed mass surrounded by an cresent of air (Monad sign).<ref name="radio">Aspergilloma. Radiopaedia (2015) http://radiopaedia.org/articles/aspergilloma Accessed on February, 9 2016</ref> | |||
===Other Diagnostic Studies=== | |||
Skin biopsy may be helpful in the diagnosis of cutaneous aspergillosis.<ref name="pmid19179225">{{cite journal| author=Mengoli C, Cruciani M, Barnes RA, Loeffler J, Donnelly JP| title=Use of PCR for diagnosis of invasive aspergillosis: systematic review and meta-analysis. | journal=Lancet Infect Dis | year= 2009 | volume= 9 | issue= 2 | pages= 89-96 | pmid=19179225 | doi=10.1016/S1473-3099(09)70019-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19179225 }} </ref><ref name="pmid9774549">{{cite journal| author=van Burik JA, Colven R, Spach DH| title=Cutaneous aspergillosis. | journal=J Clin Microbiol | year= 1998 | volume= 36 | issue= 11 | pages= 3115-21 | pmid=9774549 | doi= | pmc=PMC105285 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9774549 }} </ref> | |||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | |||
Patients with allergic bronchopulmonary aspergillosis require antifungal pharmacotherapy, as well as oral steroids and optimization of asthma control. Patients with allergic ''Aspergillus'' rhinosinusitis require de-obstruction, nasal drainage, oral steroids, immunotherapy against allergens, and allergy control. Aspergilloma fungus ball usually requires surgical resection. Chronic pulmonary aspergillosis, invasive aspergillosis, and cutaneous aspergillosis may be treated with antifungal pharmacotherapy. Surgery may be required in severe cases of cutaneous aspergillosis for debridement or amputation. | |||
===Surgery=== | ===Surgery=== | ||
Surgery is required for the treatment of | Surgery is required for the treatment of an aspergilloma fungus ball. [[Endocarditis]] caused by ''Aspergillus'' is treated by surgical repair of the heart valve. | ||
===Primary Prevention=== | ===Primary Prevention=== | ||
There is no vaccine against ''Aspergillus''. Effective preventive measures include avoiding exposure to ''Aspergillus'' by personal protective equipment in dusty environments around construction sites, avoiding activities that require exposure to soil (such as yard work or gardening), and properly cleaning wounds. Prophylactic [[antifungal]] [[drugs]] is not recommended for the general population. Pharmacologic prophylaxis may be helpful among among individual cases of immunocompromised patients. | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Fungal diseases]] | [[Category:Fungal diseases]] | ||
[[Category:Infectious disease]] | [[Category:Infectious disease]] | ||
Revision as of 00:25, 9 February 2016
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Haytham Allaham, M.D. [2]; Yazan Daaboul, M.D.; Serge Korjian M.D.
Overview
Aspergillosis is a heterogenous group of infectious diseases caused by the fungus Aspergillus (commonly A. fumigatus).
Historical Perspective
Aspergillus is an ancient mold that has first been described in animals before it was discovered to be also pathogenic in humans. The exact date of discovery of Aspergillus as a pathogenic organism is unknown.
Classification
Apergillosis may be classified according to the clinical syndrome it causes into allergic bronchopulmonary aspergillosis, allergic Aspergillus sinusitis, aspergilloma, chronic pulmonary aspergillosis, invasive aspergillosis, or cutaneous aspergillosis.
Pathophysiology
Aspergillus is primarily transmitted to the human host by inhalation of airborne conidia, dust exposure during building renovation or construction, or contaminated biomedical devices. Aspergillus is not transmitted from one individual to another. The pathogenesis of aspergillosis varies according to the associated clinical syndrome. Allergic bronchopulmonary aspergillosis and allergic Aspergillus rhinosinusitis are thought to be caused by both type I and type III hypersensitivity responses. Aspergilloma, Chronic pulmonary aspergillosis, and invasive aspergillosis are directly related to the growth and expansion of the Aspergillus hyphae in the lungs while avoiding phagocytosis by host immune cells. Cutaneous aspergillosis may result either from direct access of the Aspergillus through a skin break (primary) or dissemination of the Aspergillus to the skin from a distant infected organ (secondary).
Causes
Aspergillosis is caused by the fungus Aspergillus, commonly A. fumigatus. Aspergillus is ubiquitous in the environment.
Differential Diagnosis
Aspergillosis must be differentiated from other diseases that cause fever, chest pain, dyspnea, sinusitis, allergic symptoms, and elevated IgE concentrations. Differential diagnosis includes other infections (fungi, bacteria, viruses, and parasites), non-infectious pulmonary diseases (such as asthma, COPD, interstitial lung disease, bronchiectasis, and lung tumors), cardiac diseases (such as pericarditis, endocarditis, or myocarditis), facial diseases (such as infectious sinusitis, sinus tumor, or nasal polyps), systemic diseases (such as Hyper IgE syndrome, Churg-Strauss syndrome, granulomatosis with polyangiitis, Goodpasture's syndrome), congenital diseases (such as cystic fibrosis or ciliary dyskinesia), transplant-related complications (such as GVHD), diseases with cutaneous manifestations (such as eczema, scabies, deep vein thrombosis, cellulitis), and adverse drug reactions.
Epidemiology and Demographics
The true incidence of aspergillosis is unknown since aspergillosis is not a reportable disease in the USA.[1] The incidence of allergic bronchopulmonary aspergillosis is estimated to be 5 million worldwide.[1] In contrast, invasive aspergillosis is much less common. The incidence is thought to be approximately 1 to 2 cases per 100,000 individuals. There is no gender predilection for the development of aspergillosis. Individuals of all age groups may be affected with aspergillosis. Elderly patients with long-standing chronic lung diseases and neonates are more likely to develop aspergillosis. With the advancement of immunosuppressive therapy and higher rates of transplantation, the incidence and detection of aspergillosis is increasing in developed countries.[2]
Risk Factors
Immunocompromised status and history of prior lung disease are the most important risk factors in the development of aspergillosis. Other risk factors include history of asthma, burn or surgical site wounds, and exposure to healthcare settings or construction sites.
Natural History, Complications and Prognosis
Following transmission, the majority of patients do not develop any clinical manifestations. The incubation of Aspergillosis is highly dependent on the host immune factors. The incubation period may range from a few days to years, during which the host is asymptomatic. Among immunocompetent hosts, Aspergillosis may result in a localized pulmonary infection, allergic bronchopulmonary aspergillosis, or allergic Aspergillus sinusitis. Clinical manifestations may vary depending on the clinical syndrome. Among immunocompromised hosts, Aspergillosis progresses faster and has a more invasive course. If left untreated, aspergillosis in immunocompromised patients often progresses, and patients report worsening fever, chest pain, and hemoptysis. Invasive aspergillosis eventually invades non-pulmonary organs and becomes disseminated and life-threatening.
Diagnosis
Diagnostic Criteria
Diagnostic criteria are available for allergic bronchopulmonary aspergillosis and for allergic fungal rhinosinusitis. Major and minor diagnostic criteria are based on clinical, laboratory, and radiological findings.
History and Symptoms
Symptoms of aspergillosis are dependent on the clinical syndrome and extent of disease invasion.[3][4] Patients with allergic bronchopulmonary aspergillosis or sinusitis have symptoms typical of asthma and sinusitis, respectively. Symptoms of invasive pulmonary aspergillosis include spiking fever, pleuritic chest pain, productive cough, dyspnea, and hemoptysis. Symptoms of chronic pulmonary aspergillosis include chronic fever, weight loss, productive cough, and hemoptysis.
Physical Examination
Invasive pulmonary aspergillosis patients often appear sick-looking, lethargic, and fatigued. In contrast, patients with pulmonary aspergilloma, allergic bronchopulmonary aspergillosis, or allergic sinusitis often appear healthy. Physical examination of patients with pulmonary or invasive aspergillosis is usually remarkable for decreased breath sounds with wheezes, rales, and increased tactile fremitus. Physical examination of patients with cutaneous aspergillosis is usually remarkable for and single or multiple erythematous-to-violaceous cutaneous papules, macules, nodules, or plaques.[5][6][7]
Laboratory Findings
PCR is the method of choice for the diagnosis of aspergillosis. A single negative PCR result is sufficient to rule out aspergillosis, whereas two positive test results are required to confirm the diagnosis. Laboratory findings consistent with the diagnosis of aspergillosis include positive aspergillus antibody test, positive galactomannan test, elevated concentration of IgE immunoglobulin, and positive culture from sputum or bronchoalveolar lavage.[5][8][9]
Chest X Ray
Chest X-ray may be helpful in the diagnosis of aspergillosis. Chest X-ray may be remarkable for recurrent pulmonary infiltrates in allergic bronchopulmonary aspergillosis. Findings on chest X-ray suggestive of aspergilloma include a well demarcated, round, soft tissue mass located inside an air space cavity of the lungs.[10][11] Multiple cavities with evidence of fibrosis are suggestive of chronic pulmonary aspergillosis, whereas focal nodules and infiltration are suggestive of invasive aspergillosis.
CT Scan
Chest CT scan may be helpful in the diagnosis of aspergillosis. Findings on chest CT scan suggestive of aspergillosis include a well formed cavity, a central soft tissue attenuating oval shaped, well circumscribed mass surrounded by an cresent of air (Monad sign).[11]
Other Diagnostic Studies
Skin biopsy may be helpful in the diagnosis of cutaneous aspergillosis.[12][6]
Treatment
Medical Therapy
Patients with allergic bronchopulmonary aspergillosis require antifungal pharmacotherapy, as well as oral steroids and optimization of asthma control. Patients with allergic Aspergillus rhinosinusitis require de-obstruction, nasal drainage, oral steroids, immunotherapy against allergens, and allergy control. Aspergilloma fungus ball usually requires surgical resection. Chronic pulmonary aspergillosis, invasive aspergillosis, and cutaneous aspergillosis may be treated with antifungal pharmacotherapy. Surgery may be required in severe cases of cutaneous aspergillosis for debridement or amputation.
Surgery
Surgery is required for the treatment of an aspergilloma fungus ball. Endocarditis caused by Aspergillus is treated by surgical repair of the heart valve.
Primary Prevention
There is no vaccine against Aspergillus. Effective preventive measures include avoiding exposure to Aspergillus by personal protective equipment in dusty environments around construction sites, avoiding activities that require exposure to soil (such as yard work or gardening), and properly cleaning wounds. Prophylactic antifungal drugs is not recommended for the general population. Pharmacologic prophylaxis may be helpful among among individual cases of immunocompromised patients.
References
- ↑ 1.0 1.1 Denning DW, Pleuvry A, Cole DC (2013). "Global burden of allergic bronchopulmonary aspergillosis with asthma and its complication chronic pulmonary aspergillosis in adults". Med Mycol. 51 (4): 361–70. doi:10.3109/13693786.2012.738312. PMID 23210682.
- ↑ Definition of Aspergillosis - Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/fungal/diseases/aspergillosis/statistics.html Accessed on Feb 8 2016
- ↑ Aspergillosis. MAYO CLINIC (2015) http://www.mayoclinic.org/diseases-conditions/aspergillosis/basics/risk-factors/con-20030330 Accessed on February, 8 2016
- ↑ Kousha M, Tadi R, Soubani AO (2011). "Pulmonary aspergillosis: a clinical review". Eur Respir Rev. 20 (121): 156–74. doi:10.1183/09059180.00001011. PMID 21881144.
- ↑ 5.0 5.1 Aspergillosis. Wikipedia (2015) https://en.wikipedia.org/wiki/Aspergillosis Accessed on February, 8 2016
- ↑ 6.0 6.1 van Burik JA, Colven R, Spach DH (1998). "Cutaneous aspergillosis". J Clin Microbiol. 36 (11): 3115–21. PMC 105285. PMID 9774549.
- ↑ Samarakoon P, Soubani A (2008). "Invasive pulmonary aspergillosis in patients with COPD: a report of five cases and systematic review of the literature". Chron Respir Dis. 5 (1): 19–27. doi:10.1177/1479972307085637. PMID 18303098.
- ↑ Cuenca-Estrella M, Bassetti M, Lass-Flörl C, Rácil Z, Richardson M, Rogers TR (2011). "Detection and investigation of invasive mould disease". J Antimicrob Chemother. 66 Suppl 1: i15–24. doi:10.1093/jac/dkq438. PMID 21177400.
- ↑ Kradin RL, Mark EJ (2008). "The pathology of pulmonary disorders due to Aspergillus spp". Arch Pathol Lab Med. 132 (4): 606–14. doi:10.1043/1543-2165(2008)132[606:TPOPDD]2.0.CO;2. PMID 18384212.
- ↑ Curtis A, Smith G, Ravin C (1979). "Air crescent sign of invasive aspergillosis". Radiology. 133 (1): 17–21. PMID 472287. Unknown parameter
|month=ignored (help) - ↑ 11.0 11.1 Aspergilloma. Radiopaedia (2015) http://radiopaedia.org/articles/aspergilloma Accessed on February, 9 2016
- ↑ Mengoli C, Cruciani M, Barnes RA, Loeffler J, Donnelly JP (2009). "Use of PCR for diagnosis of invasive aspergillosis: systematic review and meta-analysis". Lancet Infect Dis. 9 (2): 89–96. doi:10.1016/S1473-3099(09)70019-2. PMID 19179225.