243.2 📚 國考版

243.2.0.1 必背 — 5 Clinical Forms

1. Invasive aspergillosis (IA) — immunocompromise; severe; high mortality
2. ABPA — asthma + CF; IgE-mediated allergic; corticosteroids + itraconazole
3. Aspergilloma — pre-existing cavity (post-TB); fungal ball; hemoptysis; surgical / embolization
4. Chronic pulmonary aspergillosis — underlying lung disease; long-term azole
5. Cutaneous + sinus + ocular + ENT — local invasion

243.2.0.2 必背 — Invasive Aspergillosis Risk

• Neutropenia (prolonged)
• HSCT + transplant
• Anti-CD20 + anti-TNF + steroids
• Advanced HIV (CD4 < 50)
• Severe COPD with steroids
• Severe influenza + COVID-19 (post-viral)
• CGD

243.2.0.3 必背 — Chest CT Signs

• Halo sign (ground-glass around nodule) — early IA, neutropenic
• Air crescent sign — recovery phase (neutrophil restoration)
• Cavitary mass with intracavitary fungal ball — aspergilloma (crescent sign)

243.2.0.4 必背 — Diagnostic Biomarkers

• Galactomannan (GM) — Aspergillus cell wall
  • Serum: screening
  • BAL: more sensitive than serum
  • False+ : pip-tazo (old), other molds, lab issues
• β-D-Glucan: elevated in IA, Candida, PJP (not specific)
• Tissue hyphae 45° branching with septations (Aspergillus characteristic)

243.2.0.5 必背 — IA Treatment

• Voriconazole first-line (6 mg/kg IV q12h × 2 then 4 mg/kg IV q12h)
• TDM trough 1-5.5 mg/L
• Isavuconazole alternative (linear PK, less drug interactions, fewer side effects)
• Liposomal AmB for failure / intolerance
• 6-12+ weeks duration
• Reduce immunosuppression + surgery for selected

243.2.0.6 必背 — ABPA

• Asthma + CF
• Total IgE > 1000 IU/mL
• Aspergillus IgE + Aspergillus IgG (precipitins) positive
• Eosinophilia + central bronchiectasis + mucous plugging
• Treatment: systemic corticosteroids + itraconazole 16 wk
• Omalizumab for refractory / severe

243.2.0.7 必背 — Aspergilloma

• Pre-existing lung cavity (post-TB, sarcoidosis, COPD, lung abscess)
• “Crescent sign” / “air-meniscus sign” on CXR/CT
• Hemoptysis primary symptom (can be massive)
• Surgical resection for symptomatic + lobar; bronchial artery embolization for hemoptysis
• Antifungal limited efficacy

243.2.0.8 必背 — Azole-Resistant Aspergillus

• TR34/L98H mutation in CYP51A
• Netherlands first, now Asia + Europe + USA
• Caused by agricultural azole fungicide use
• Liposomal AmB or isavuconazole alternative

243.2.0.9 必背 — Severe Influenza / COVID + IA

• Increased recognition: severe influenza + COVID-19 + ICU patients on steroids → IA risk
• “Influenza-Associated Pulmonary Aspergillosis (IAPA)” + “COVID-Associated Pulmonary Aspergillosis (CAPA)”
• Active surveillance + BAL GM + early empirical treatment in suspected
• Voriconazole or isavuconazole

243.2.0.10 必背 — A. terreus

• Intrinsic Amphotericin B resistance
• Use voriconazole or isavuconazole

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