What are the key clinical features that differentiate invasive aspergillosis from chronic pulmonary aspergillosis in a primary care setting?

Invasive aspergillosis (IA) typically presents acutely with systemic and respiratory symptoms such as fever, pleuritic chest pain, haemoptysis, and rapidly progressive respiratory failure, often in immunocompromised patients or those with severe underlying lung disease. In contrast, chronic pulmonary aspergillosis (CPA) usually manifests with a more indolent course characterized by chronic cough, weight loss, fatigue, and haemoptysis over months to years, often in patients with pre-existing lung conditions like COPD or prior tuberculosis.

In primary care, the key differentiating clinical features include the rapid onset and severity of symptoms in IA versus the slow progression and chronicity in CPA. IA patients may appear acutely unwell with systemic signs of infection, whereas CPA patients often have stable but persistent respiratory symptoms and constitutional complaints.

Radiologically, IA may show nodules with halo signs or cavitary lesions with surrounding consolidation, while CPA typically presents with one or more pulmonary cavities, sometimes with fungal balls (aspergillomas) inside. However, such imaging findings require specialist referral for confirmation.

Laboratory findings in IA may include positive serum galactomannan and elevated inflammatory markers, reflecting invasive infection, whereas CPA diagnosis relies more on chronic symptoms, radiological evidence, and positive Aspergillus-specific IgG serology rather than acute markers.

Therefore, in primary care, the clinical suspicion of IA should be raised in acutely deteriorating, immunocompromised patients with rapid respiratory decline, while CPA should be considered in patients with chronic respiratory symptoms and risk factors for structural lung disease. Early referral for specialist assessment and imaging is essential for both conditions.

This integrated approach aligns with UK guidelines emphasizing clinical context and symptom duration NICE NG12, while recent literature highlights the diagnostic challenges and importance of differentiating these entities in patients with COPD and other chronic lung diseases Zhang 2024.