Response

Response

We thank the correspondents for their interest in our lesson of the month ‘A cough that doesn't fit the mould’. The two points highlighted regarding the investigation and treatment of Aspergillus infection are important and highlight the difficulties in diagnosis and then optimal treatment of this infection.

We acknowledge the limitations of the cited normal range for Aspergillus IgG and would agree that this test should not be used in isolation to diagnose invasive Aspergillosis. As stated in our case and in the medical literature,¹ a combination of the clinical scenario, blood serologies (including Aspergillus IgG and IgE), radiology, sputum microscopy and culture and tissue biopsy should be used to form the diagnosis. We thank the correspondents for emphasising the important point that a diagnosis of invasive Aspergillus disease must be reached by such a synthesis of clinical information.

The correspondents’ observations regarding the optimal treatment in this case are also important concerns. We agree that voriconazole should not be first-line therapy for clinical presentations such as that reported; our patient initially received physiotherapy and mucus plug removal via bronchoscopy. It was only after this failed to improve his symptoms that voriconazole was added and this, along with a second bronchoscopy resulted in resolution of his right lower lobe collapse.

As is observed, optimal management of cases such as this is uncertain given their rarity and the absence of robust medical literature. Management must be extrapolated from what evidence does exist. A randomised study of treatment for 3 months with voriconazole compared with amphotericin B for invasive aspergillosis resulted in fewer side effects and improved survival.² This trial was conducted in a group with significant immunocompromise following treatment for haematological malignancy. The study duration in this case, in addition to clinical practice in other areas of pulmonary aspergillosis, led to the decision to treat for 3 months. Such decisions must be made in the context of the clinical case. Further studies are needed both to determine the need for treatment and also whether shorter courses of therapy may be effective.