Although Aspergillosis occurs almost only in severely immunocompromised patients, it is not AIDS defining. In the largest series described worldwide to date with 342 cases of invasive aspergillosis in HIV, almost all patients had less than 50 CD4 cells/^l (Mylonakis 1998). The main manifestation is in the lung (pneumonia, tracheobronchitis), but extrapulmonary infections can occur. These usually involve the CNS, but can principally be localized everywhere (Mylonakis 2000). Aspergillosis particularly occurs in HIV infected patients on long-term (too long) steroid treatment for another OI. Severe neutropenia (< 1,000 leucocytes) is another risk factor. Aspergillus fumigatus is by far the most frequent pathogen (>90 %) followed by A. niger, A. terreus, A. flavus and A. nidulans. The patients, who are usually severely ill, complain of fever, cough, dyspnea and chest pain. Hemoptysis frequently occurs. Other manifestations include sinusitis or abscesses (kidneys, liver) (Hunt 2000).
The only way to reach a reliable diagnosis is biopsy. A serum antigen test for As-pergillus galactomannan can support the suspected diagnosis. Even proof of Asper-gillus in pulmonary secretions is an indication of infection, although often dependent on colonization. Chest x-ray is often unremarkable. On HR-CT, pulmonary collections with a halo or cavitating lesions are suspicious for Aspergillosis.
Antimycotic therapy should be started as soon as Aspergillosis is suspected. Every delay significantly worsens the already poor prognosis - do not wait for the microbiological proof from the biopsy! Voriconazole is currently the therapy of choice, as a randomized study showed higher response rates than for amphotericin B (Herbrecht 2002). Voriconazole is given as 2 x 4 mg i.v./kg/day (loading dose 2 x 6 mg/kg on day 1, changing to oral therapy with 2 x 200 mg/day on day 7). It has the advantage of effective penetration into the brain parenchyma (Schwartz 2005), but causes visual disturbances in 20 % and often (reversible) elevation of liver enzymes. Amphotericin B is the alternative to voriconazole, although its inferiority is doubted by some authors (Jorgensen 2006). In cases of intolerance, contraindications or therapeutic failure, liposomal amphotericin B, capsofungin, posaconazole or high dose itraconazole can be considered. Systemic steroid therapy should be discontinued.
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