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| ==Diagnose== | | ==Diagnose== |
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| ===3.2 Diagnostische Schritte===
| | {{DGI:Invasive Aspergillose/Diagnose/Diagnostische Schritte}} |
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| mso-bidi-language:AR-SA">Angestrebte Diagnostik variiert je nach (vermutetem) Organbefall. Die häufigste Form ist die invasive pulmonale Aspergillose. Daher sollten, wenn möglich, eine Computertomographie (CT) des Thorax erfolgen. Hier zeigen sich eine oder mehrere noduläre Verdichtungen, sogenannte Noduli mit oder ohne Höhlenbildung. Sie zeigen sich peribronchiolär und das sogenannte Tree-in-Bud-Muster (Blütenzweig-Muster) aufweisen. Typisch ist das sogenannte Halo-Zeichen, ein milchglasartiges Infiltrat, das einen Nodulus zirkulär umgibt. Es ist vermutlich das radiologische Korrelat für die an den Infektionsherd angrenzende Einblutung und wird typischerweise bei neutropenischen (und dann auch thrombozytopenischen) Patienten beschrieben.</span><ref>18. <span style="mso-tab-count:1"> </span>Georgiadou SP, Sipsas NV, Marom EM, Kontoyiannis DP. The diagnostic value of halo and reversed halo signs for invasive mold infections in compromised hosts. ''Clin Infect Dis'' 2011; '''52'''(9): 1144-55.</ref><span style="font-size:11.0pt;line-height:107%;font-family:"Calibri",sans-serif;
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| mso-bidi-language:AR-SA"><sup><span style="mso-no-proof:yes">18</span></sup></span><span style="font-size:
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| AR-SA"> Während adäquater Therapie kann es zunächst zu einer Größenzunahme der Infiltrate kommen, bevor das Infiltrat bis auf eine Narbe schrumpft. Eine Form der Defektheilung ist die Bildung einer Höhle, die ggf. Pilz- und Nekrosematerial enthält. Im CT kann dies als sogenanntes Luftsichel-Zeichen (engl. air-crescent) auffallen.</span><ref>19. <span style="mso-tab-count:1"> </span>Caillot D, Casasnovas O, Bernard A, et al. Improved management of invasive pulmonary aspergillosis in neutropenic patients using early thoracic computed tomographic scan and surgery. ''Journal of clinical oncology : official journal of the American Society of Clinical Oncology'' 1997; '''15'''(1): 139-47.
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| <br /></ref><ref>20. <span style="mso-tab-count:1"> </span>Caillot D, Couaillier JF, Bernard A, et al. Increasing volume and changing characteristics of invasive pulmonary aspergillosis on sequential thoracic computed tomography scans in patients with neutropenia. ''Journal of clinical oncology : official journal of the American Society of Clinical Oncology'' 2001; '''19'''(1): 253-9.<br /></ref><span style="font-size:11.0pt;line-height:107%;font-family:"Calibri",sans-serif;
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| mso-bidi-language:AR-SA"><sup><span style="mso-no-proof:yes">19,20</span></sup></span><span style="font-size:
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| AR-SA"> Bei Patienten mit großen nodulären Infiltraten kann eine CT-Angiographie Aufschluss über eine mögliche Angioinvasivität geben und so Sensitivität und Spezifität der Bildgebung erhöhen.</span><ref><span style="mso-ansi-language:DE">21. <span style="mso-tab-count:1"> </span>Stanzani M, Battista G, Sassi C, et al. </span>Computed tomographic pulmonary angiography for diagnosis of invasive mold diseases in patients with hematological malignancies. ''Clin Infect Dis'' 2012; '''54'''(5): 610-6.
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| <br /></ref><ref>22. <span style="mso-tab-count:1"> </span>Stanzani M, Sassi C, Lewis RE, et al. High resolution computed tomography angiography improves the radiographic diagnosis of invasive mold disease in patients with hematological malignancies. ''Clin Infect Dis'' 2015; '''60'''(11): 1603-10.<br /></ref><span style="font-size:11.0pt;line-height:107%;font-family:"Calibri",sans-serif;
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| mso-bidi-language:AR-SA"><sup><span style="mso-no-proof:yes">21,22</span></sup></span><span style="font-size:
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| AR-SA"> Die radiologischen Befunde können jedoch sehr variabel sein. Daher sind Differentialdiagnosen unbedingt auszuschließen. Bei allen Patienten mit pilztypischen Infiltraten im CT Thorax sollte daher die Durchführung einer bronchoalveolären Lavage mit Probengewinnung erfolgen.</span><ref>23. <span style="mso-tab-count:1"> </span>Sampsonas F, Kontoyiannis DP, Dickey BF, Evans SE. Performance of a standardized bronchoalveolar lavage protocol in a comprehensive cancer center: a prospective 2-year study. ''Cancer'' 2011; '''117'''(15): 3424-33.<br /></ref><ref>24. <span style="mso-tab-count:1"> </span>Shannon VR, Andersson BS, Lei X, Champlin RE, Kontoyiannis DP. Utility of early versus late fiberoptic bronchoscopy in the evaluation of new pulmonary infiltrates following hematopoietic stem cell transplantation. ''<span style="mso-ansi-language:DE">Bone marrow transplantation</span>'' <span style="mso-ansi-language:DE">2010; '''45'''(4): 647-55.</span><br /></ref><span style="font-size:11.0pt;line-height:107%;font-family:"Calibri",sans-serif;
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| mso-bidi-language:AR-SA"><sup><span style="mso-no-proof:yes">23,24</span></sup></span><span style="font-size:
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| AR-SA"> Mikroskopische, kulturelle, serologische und molekulargenetische Untersuchungen der Proben sind zur Diagnosefindung unabdingbar. Kulturell lassen sich zusätzlich Resistenztestungen durchführen, die unter Umständen eine Anpassung der antimykotischen Therapie notwendig machen. Serologisch kann man aus Lavageflüssigkeit und aus dem Blut Galactomannan nachweisen. Aus Serum empfiehlt es sich Proben an drei aufeinander folgenden Tagen zu analysieren.</span><ref><span style="mso-ansi-language:DE">25. <span style="mso-tab-count:1"> </span>Maertens J, Theunissen K, Verbeken E, et al. </span>Prospective clinical evaluation of lower cut-offs for galactomannan detection in adult neutropenic cancer patients and haematological stem cell transplant recipients. ''British journal of haematology'' 2004; '''126'''(6): 852-60.
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| <br /></ref><ref>26. <span style="mso-tab-count:1"> </span>Marr KA, Balajee SA, McLaughlin L, Tabouret M, Bentsen C, Walsh TJ. Detection of galactomannan antigenemia by enzyme immunoassay for the diagnosis of invasive aspergillosis: variables that affect performance. ''J Infect Dis'' 2004; '''190'''(3): 641-9.</ref><ref>27. <span style="mso-tab-count:1"> </span>Miceli MH, Maertens J. Role of Non-Culture-Based Tests, with an Emphasis on Galactomannan Testing for the Diagnosis of Invasive Aspergillosis. ''Semin Respir Crit Care Med'' 2015; '''36'''(5): 650-61.
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| 28. <span style="mso-tab-count:1"> </span>Pfeiffer CD, Fine JP, Safdar N. Diagnosis of invasive aspergillosis using a galactomannan assay: a meta-analysis. ''Clin Infect Dis'' 2006; '''42'''(10): 1417-727.
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| mso-bidi-language:AR-SA"><sup><span style="mso-no-proof:yes">25-28</span></sup></span><span style="font-size:
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| AR-SA"> Zum algorithmusgesteuerten Diagnostik eignet sich der EQUAL Asergillosis Score 2018 (Abbildung 1A und B).</span><ref>29. <span style="mso-tab-count:1"> </span>Cornely OA, Koehler P, Arenz D, S CM. EQUAL Aspergillosis Score 2018: An ECMM score derived from current guidelines to measure QUALity of the clinical management of invasive pulmonary aspergillosis. ''Mycoses'' 2018; '''61'''(11): 833-6.<br /></ref><span style="font-size:11.0pt;line-height:107%;font-family:"Calibri",sans-serif;
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| mso-bidi-language:AR-SA"><sup><span style="mso-no-proof:yes">29</span></sup></span>
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