respiratory investigation 54 (2016) 75
Contents lists available at ScienceDirect
Respiratory Investigation journal homepage: www.elsevier.com/locate/resinv
Editorial
Update and recent advances on the management of invasive and chronic pulmonary aspergillosis A large amount of information on deep-seated mycosis, including pulmonary aspergillosis, has been recently accumulated, and the guidelines for its management have been published in many countries, including Europe, the United States of America, and Japan. Although various types of pulmonary aspergillosis were recognized in the past, they have recently been categorized as invasive pulmonary aspergillosis (IPA), chronic pulmonary aspergillosis (CPA), and allergic bronchopulmonary aspergillosis. However, studies regarding deep-seated mycosis are limited and its management remains controversial. Therefore, reviews regarding invasive fungal diseases, especially the review on aspergillosis by Geltner [1] and chronic pulmonary aspergillosis (CPA) by Izumikawa [2], would provide us with new information based on recent evidences. The review by Geltner focuses on IPA, typically occurring in patients undergoing stem cell and organ transplantations. Organ transplantations have been increasing worldwide, with no exception in Japan, and the patients most commonly affected by fungal infections are the ones undergoing lung transplantation. Since the typical manifestation of fungal infection is lung involvement, which has a high mortality rate, it is important for pulmonologist to recognize invasive pulmonary mycosis, especially IPA. This review summarized the incidence and frequency of filamentous fungal infection, site of lung involvement, diagnostic methods, usefulness of antifungal prophylaxis, and therapeutic strategies including the emergence of drug resistance. Interestingly, bronchoscopic examination, as shown in the figures of the bronchoscopic views in this review, has been useful in diagnosing bronchial aspergillosis and fungal invasions such as tracheobronchial aspergillosis and anastomositis after lung transplantation. Additionally, immune reconstitution syndrome as a new pathogenetic mechanism of lung disease would be worthy of special mention. A published review by Izumikawa provides the latest information on CPA mainly based on studies conducted in Japan, and it includes information stated in the revised Japanese Guidelines for management of deep-seated mycosis published in 2014. The focus of this review was to describe a new entity of CPA. As observed in the last decade, the entities of chronic forms of aspergillosis have been extremely complicated involving several subtypes such as chronic necrotizing pulmonary
aspergillosis (CNPA), chronic cavitary pulmonary aspergillosis (CCPA) with partly chronic fibrosing pulmonary aspergillosis, and aspergilloma (simple aspergilloma [SA]). However, it may be difficult to distinguish these subtypes, except for SA, involving chronic infiltration, progressive cavitation, and subsequent aspergilloma formation during the clinical process of CPA. Therefore, a new term “chronic progressive pulmonary aspergillosis,” which includes CNPA and CCPA, was proposed for better understanding and management of CPA. Based on these new categories of CPA, the review described the epidemiology and underlying diseases, including chronic obstructive pulmonary disease as a major risk factor for CPA; useful methods for its diagnosis; recent advances of antifungal therapy, including the pharmacodynamic/pharmacokinetic strategies; the emergence of antifungal (azole) resistance. These two reviews would be of great use to the physicians managing fungal diseases. However, more studies regarding appropriate early diagnostic methods and therapeutic strategies for managing fungal infections, including the rarely reported mucormycetes, are necessary in the future.
Associate Editor Jun-ichi Kadota Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Japan
r e f e r e nc e s
[1] Geltner C, Lass-Florl C. Invasive pulmonary aspergillosis in organ transplants – focus on lung transplants. Respir Investig 2016;54:76–84. [2] Izumikawa K. Recent advances in chronic pulmonary aspergillosis. Respir Investig 2016;54:85–91.
http://dx.doi.org/10.1016/j.resinv.2016.02.001 2212-5345/& 2016 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.
Contents lists available at ScienceDirect
Respiratory Investigation journal homepage: www.elsevier.com/locate/resinv
Editorial
Update and recent advances on the management of invasive and chronic pulmonary aspergillosis A large amount of information on deep-seated mycosis, including pulmonary aspergillosis, has been recently accumulated, and the guidelines for its management have been published in many countries, including Europe, the United States of America, and Japan. Although various types of pulmonary aspergillosis were recognized in the past, they have recently been categorized as invasive pulmonary aspergillosis (IPA), chronic pulmonary aspergillosis (CPA), and allergic bronchopulmonary aspergillosis. However, studies regarding deep-seated mycosis are limited and its management remains controversial. Therefore, reviews regarding invasive fungal diseases, especially the review on aspergillosis by Geltner [1] and chronic pulmonary aspergillosis (CPA) by Izumikawa [2], would provide us with new information based on recent evidences. The review by Geltner focuses on IPA, typically occurring in patients undergoing stem cell and organ transplantations. Organ transplantations have been increasing worldwide, with no exception in Japan, and the patients most commonly affected by fungal infections are the ones undergoing lung transplantation. Since the typical manifestation of fungal infection is lung involvement, which has a high mortality rate, it is important for pulmonologist to recognize invasive pulmonary mycosis, especially IPA. This review summarized the incidence and frequency of filamentous fungal infection, site of lung involvement, diagnostic methods, usefulness of antifungal prophylaxis, and therapeutic strategies including the emergence of drug resistance. Interestingly, bronchoscopic examination, as shown in the figures of the bronchoscopic views in this review, has been useful in diagnosing bronchial aspergillosis and fungal invasions such as tracheobronchial aspergillosis and anastomositis after lung transplantation. Additionally, immune reconstitution syndrome as a new pathogenetic mechanism of lung disease would be worthy of special mention. A published review by Izumikawa provides the latest information on CPA mainly based on studies conducted in Japan, and it includes information stated in the revised Japanese Guidelines for management of deep-seated mycosis published in 2014. The focus of this review was to describe a new entity of CPA. As observed in the last decade, the entities of chronic forms of aspergillosis have been extremely complicated involving several subtypes such as chronic necrotizing pulmonary
aspergillosis (CNPA), chronic cavitary pulmonary aspergillosis (CCPA) with partly chronic fibrosing pulmonary aspergillosis, and aspergilloma (simple aspergilloma [SA]). However, it may be difficult to distinguish these subtypes, except for SA, involving chronic infiltration, progressive cavitation, and subsequent aspergilloma formation during the clinical process of CPA. Therefore, a new term “chronic progressive pulmonary aspergillosis,” which includes CNPA and CCPA, was proposed for better understanding and management of CPA. Based on these new categories of CPA, the review described the epidemiology and underlying diseases, including chronic obstructive pulmonary disease as a major risk factor for CPA; useful methods for its diagnosis; recent advances of antifungal therapy, including the pharmacodynamic/pharmacokinetic strategies; the emergence of antifungal (azole) resistance. These two reviews would be of great use to the physicians managing fungal diseases. However, more studies regarding appropriate early diagnostic methods and therapeutic strategies for managing fungal infections, including the rarely reported mucormycetes, are necessary in the future.
Associate Editor Jun-ichi Kadota Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Japan
r e f e r e nc e s
[1] Geltner C, Lass-Florl C. Invasive pulmonary aspergillosis in organ transplants – focus on lung transplants. Respir Investig 2016;54:76–84. [2] Izumikawa K. Recent advances in chronic pulmonary aspergillosis. Respir Investig 2016;54:85–91.
http://dx.doi.org/10.1016/j.resinv.2016.02.001 2212-5345/& 2016 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.
