We are wondering if Serum  IgE will be useful before doing a CT guided FNAC

Dear Sangeetha Sampath - Aspergillus is an interesting organism. As you know the same organism causes three completely different diseases:

1. Systemic/ Invasive aspergillosis - which I assume you are concerned about here - test for serum Galactomannan.

2. Allergic bronchopulmonary aspergillosis - leading to asthma and bronchiectasis ( wihich has a positive IgE ) and

3. Aspergilloma - a fungal ball in a pre-existing cavity where Aspergillus precipitins (not IgE) is raised

So as you can see, it appears it is better for you to proceed with obtaining FNAC/ BAL - which of course is not without risk

You may find the recent article in Medical Mycology by Escribano from Madrid helpful:

Med Mycol. 2015 Jan 28. pii: myu090.

Sputum and bronchial secretion samples are equally useful as bronchoalveolar lavage samples for the diagnosis of invasive pulmonary aspergillosis in selected patients.

Hope this helps, Best wishes

Don't forget to' dose galattomannan, both in blood and bal. It is extremely accurate for invasive aspergillosis

Thank you.  checking on culturing repeat sample and blood culture. Will check out where galactomannan is done in my city

Did the patient have any other clinical or laboratory abnormalities? Has the patient a smoking history? Have you checked for rare causes like ANCA postive vasculitis?

This presentation is consistent with chronic pulmonary aspergillosis. The aspergillus in sputum could be significant or could be contaminant. Serological tests may help confirm the diagnosis. A serum galactomannan is unlikely to be positive in CPA (unlike in invasive aspergillosis). In serum, you can do Aspergillus precipitins and Aspergillus IgG. Total IgE will nor be helpful as this is not ABPA picture. If positive, they can support the diagnosis.

The radiological picture of many fluid filled cavities is not typical for CPA however. A CT scan may be more specific as it may show an aspergilloma .There could be an other condition like vasculitis, tumor or bacterial abscesses.

I would do a BAL, CT guided biopsy and vasculitis screen. If all negative, then you could treat for aspergillus with itraconazole.

If the same fungus (this, at least, implies to identify the Aspergillus species) is repeatedly isolated from your patient’s respiratory sample, the patient is at least a colonized by it and you can rule out with confidence a contamination of the sample. As stated before in the discussion: Aspergillus disease is highly polymorphic; and you have two major diagnostic tools: chest CT scan and serum galactomannan antigen detection. If the GM Ag is positive it would be highly predictive of an invasive aspergillosis in your patients’ context. If GM Ag is negative but, the CT scan images are compatible and there is no documented differential diagnosis, I would advise to treat with a systemic antifungal, preferentially, if available, voriconazole.

The patient has now been diagnosed with adenocarcinoma-rectum. Also we got Aspergillus fumigatus on repeat culture.  Thank you all for your useful suggestions 

Dear Sangeeta,

Did you get Galactomannan test done in this case? Did it help?

BAL for Galactomannan is more specific for Aspergillosis than serum Galactomannan

We could not get it done as it was not available in our city.

call metropolis labs and see if they can help u in getting the test done

You can send cavity swab or biopsy for fungal culture examination or histipathology. You can also do antibodies detection from blood