A 55-year-old man on long-term steroids for ILD develops fever, haemoptysis, and a CT chest showing a cavitary lesion with 'halo sign' (zone of consolidation surrounding a central nodule). Bronchoalveolar lavage Galactomannan index is 3.2 (positive >0.5). Fungal culture grows septate hyphae with V-shaped branching at 45°. What is the most appropriate first-line treatment?

• A Fluconazole 400 mg IV daily
• B Amphotericin B deoxycholate IV with flucytosine
• C Itraconazole oral solution for 6 months
• D Voriconazole 6 mg/kg IV BD (loading) then 4 mg/kg IV BD (maintenance) ✓

Explanation

The CT halo sign, positive BAL galactomannan, and septate hyphae with acute-angle (45°) branching in a V-shape are characteristic of invasive pulmonary aspergillosis (IPA) caused by Aspergillus fumigatus. Voriconazole (a triazole with excellent Aspergillus coverage) is the first-line treatment for IPA as established by the IDSA/ESCMID guidelines; it demonstrated superiority over amphotericin B in the pivotal Herbrecht trial. Fluconazole has no activity against Aspergillus. Itraconazole is used for chronic pulmonary aspergillosis, not acute invasive disease.

Reference: Ananthanarayan & Paniker's Textbook of Microbiology, 11th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.