Internal Medicine

P1: SBT

0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8

170 Aspergillosis

Combination therapy – observational studies have suggested

some benefit in salvage regimens (ampho+itra, liposomal

ampho+caspofungin, vori+caspofungin) but there have

been no randomized controlled trials to show efficacy.

Corticosteroids are used for exacerbations of ABPA.

■Surgery:

➣Excision may be helpful for some cases of localized pulmonary

disease.

➣Surgical debridement can be curative in invasive sinus disease

but may increase mortality in neutropenic patients.

➣In brain abscesses, surgical drainage has an important diagnostic

and therapeutic role.

Side Effects & Contraindications

Voriconazole:

Side effects: vision changes, nausea, fever, rash, elevated LFTs

Contraindications: many drug-drug interactions

■Amphotericin B:

➣Side effects: fevers, chills, nausea, vomiting and headaches; rig-

ors may be prevented by the addition of hydrocortisone to

bag, meperidine may treat rigors; nephrotoxicity; electrolyte

disturbance (renal tubular acidosis, hypokalemia, hypomagne-

semia)

➣Contraindications: if Cr 2.5–3.0, may consider giving lipid-based

amphotericin product

■Itraconazole:

➣Side effects: nausea, vomiting, anorexia, abdominal pain, rash;

rarely hypokalemia and hepatitis

➣Contraindications: end-stage renal disease for cyclodextran

solution; lower cyclosporin dose when concomitantly given; may

dangerously increase serum levels of digoxin and loratadine,

causing fatal arrhythmias

follow-up

■Duration of therapy is unknown, but for severe invasive disease, most

treat with voriconazole IV then PO or amphotericin IV+/−follow-up

itraconazole therapy depending on clinical response.

■Follow patients for clinical improvement, resolution of underlying

risk factors (this may be the most important factor) and radiographic

resolution of lesions.