Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria

Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Eosinophilic Lung Diseases

Eosinophilic lung diseases especially comprise eosinophilic pneumonia or as the more transient Löffler syndrome, which is most often due to parasitic infections. The diagnosis of eosinophilic pneumonia is based on characteristic clinical-imaging features and the demonstration of alveolar eosinophilia, defined as at least 25% eosinophils at BAL. Peripheral blood eosinophilia is common but may be absent at presentation in idiopathic acute eosinophilic pneumonia, which may be misdiagnosed as severe infectious pneumonia. All possible causes of eosinophilia, including drug, toxin, fungus related etiologies, must be thoroughly investigated. Extrathoracic manifestations should raise the suspicion of eosinophilic granulomatosis with polyangiitis.

Allergic Bronchopulmonary Aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA), a progressive fungal allergic lung disease, is a common complication of asthma or cystic fibrosis. Although ABPA has been recognized since the 1950s, recent research has underscored the importance of Th2 immune deviation and granulocyte activation in its pathogenesis. There is also strong evidence of widespread under-diagnosis due to the complexity and lack of standardization of diagnostic criteria. Treatment has long focused on downregulation of the inflammatory response with prolonged courses of oral glucocorticosteroids, but more recently concerns with steroid toxicity and availability of new treatment modalities has led to trials of oral azoles, inhaled amphotericin, pulse intravenous steroids, and subcutaneously-injected anti-IgE monoclonal antibody omalizumab, all of which show evidence of efficacy and reduced toxicity.

Coexisting atopic conditions influence the likelihood of allergic bronchopulmonary aspergillosis in asthma

BACKGROUND

The diagnosis of allergic bronchopulmonary aspergillosis (ABPA) in asthma is often made in patients with total serum IgE levels greater than 1,000 IU/mL in conjunction with evidence of Aspergillus sensitization. The specificity of total serum IgE for the diagnosis of ABPA is low even when combined with serum Aspergillus specific IgE.

OBJECTIVE

To determine the prevalence of ABPA and to identify alternative clinical predictors for ABPA among asthmatic patients with a total serum IgE level greater than 1,000 IU/ml.

METHODS

This study was conducted in a tertiary hospital in Melbourne, Australia, with a large asthma and allergy service. Patients with asthma and total serum IgE levels greater than 1,000 IU/ml from January 1, 2005, through December 31, 2014, were included. Patients were considered to have concomitant allergic conditions if they had atopic eczema, allergic rhinitis, or both. The diagnosis of ABPA was based on the managing physician's documented diagnosis and referenced to criteria proposed by the International Society for Human and Fungal Mycology.

RESULTS

The prevalence of ABPA in our cohort was 15.8%. Older age, elevated total serum IgE level, reduced lung function, and the absence of other concomitant allergic conditions increased the risk of ABPA. After multivariate logistic regression, patients without concomitant allergic conditions had an odds ratio of 4.4 (95% confidence interval, 1.9-10.1; P = .001) for ABPA when compared with patients with allergic conditions.

CONCLUSION

The absence of atopic eczema and allergic rhinitis in these patients increases the likelihood of ABPA. Eliciting an accurate allergy history may be a useful bedside clinical tool when considering the diagnosis of ABPA.

Aspergillus infections in cystic fibrosis

Patients with cystic fibrosis (CF) suffer from chronic lung infection and airway inflammation. Respiratory failure secondary to chronic or recurrent infection remains the commonest cause of death and accounts for over 90% of mortality. Bacteria as Staphylococcus aureus, Pseudomonas aeruginosa and Burkholderia cepacia complex have been regarded the main CF pathogens and their role in progressive lung decline has been studied extensively. Little attention has been paid to the role of Aspergillus spp. and other filamentous fungi in the pathogenesis of non-ABPA (allergic bronchopulmonary aspergillosis) respiratory disease in CF, despite their frequent recovery in respiratory samples. It has become more apparent however, that Aspergillus spp. may play an important role in chronic lung disease in CF. Research delineating the underlying mechanisms of Aspergillus persistence and infection in the CF lung and its link to lung deterioration is lacking. This review summarizes the Aspergillus disease phenotypes observed in CF, discusses the role of CFTR (cystic fibrosis transmembrane conductance regulator)-protein in innate immune responses and new treatment modalities.

Multidetector Computed Tomography and MR Imaging Findings in Mycotic Infections

Fungal infections constitute a diverse spectrum of infections with variable clinical and imaging features. They are commonly opportunistic infections that affect immunocompromised individuals secondary to inherited or acquired disorders. Fungal infections may affect multiple organ systems and contribute to significant morbidity and mortality. Although the imaging features of some fungal infections are characteristic and permit their diagnosis, many mycotic infections manifest nonspecific findings. Definitive diagnosis often depends on histopathological analysis. Early diagnosis requires both clinical suspicion and supporting radiological evidence. Early treatment results in reduced morbidity and mortality. This article reviews the imaging findings in opportunistic and endemic fungal infections.

Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity

In susceptible individuals, inhalation of Aspergillus spores can affect the respiratory tract in many ways. These spores get trapped in the viscid sputum of asthmatic subjects which triggers a cascade of inflammatory reactions that can result in Aspergillus-induced asthma, allergic bronchopulmonary aspergillosis (ABPA), and allergic Aspergillus sinusitis (AAS). An immunologically mediated disease, ABPA, occurs predominantly in patients with asthma and cystic fibrosis (CF). A set of criteria, which is still evolving, is required for diagnosis. Imaging plays a compelling role in the diagnosis and monitoring of the disease. Demonstration of central bronchiectasis with normal tapering bronchi is still considered pathognomonic in patients without CF. Elevated serum IgE levels and Aspergillus-specific IgE and/or IgG are also vital for the diagnosis. Mucoid impaction occurring in the paranasal sinuses results in AAS, which also requires a set of diagnostic criteria. Demonstration of fungal elements in sinus material is the hallmark of AAS. In spite of similar histopathologic features, co-existence of ABPA and AAS is still uncommon. Oral corticosteroids continue to be the mainstay of management of allergic aspergillosis. Antifungal agents play an adjunctive role in ABPA as they help reduce the fungal load. Saprophytic colonization in cavitary ABPA may lead to aspergilloma formation, which could increase the severity of the disease. The presence of ABPA, AAS, and aspergilloma in the same patient has also been documented. All patients with Aspergillus-sensitized asthma must be screened for ABPA, and AAS should always be looked for.

Fungal sensitisation in severe asthma is associated with the identification of Aspergillus fumigatus in sputum

BACKGROUND

Fungal sensitisation is an important factor in severe asthma, not only for allergic bronchopulmonary aspergillosis (ABPA) but also the more recently described severe asthma with fungal sensitisation (SAFS). It is not known whether these diseases are driven by the presence of airway fungal colonisation. We aimed to determine if both SAFS and ABPA were associated with airway isolation of Aspergillus fumigatus and whether the frequency of isolation changed following anti-fungal treatment.

METHODS

Sputum samples were collected from patients with SAFS, ABPA and a control group without fungal sensitisation. We recorded details of antifungal treatment, serum IgE and A. fumigatus specific IgE levels. In a subgroup (n = 9) we recorded serial sputum PCR measurements before and during itraconazole therapy.

RESULTS

244 sputum samples were provided by 135 patients, 41(17%) ABPA, 168(69%) SAFS, and 35(14%) controls. Sputum Aspergillus fumigatus PCR was positive in 61 SAFS patients (70%) and 6 ABPA patients (50%) not on anti-fungal treatment at the time of the test, compared to 3 (9%) in controls (χ(2) = 37.90, p < 0.001). Consequently, 19 patients with SAFS who were taking antifungal treatment (23%) were significantly less likely to be PCR positive than the 61 patients not on treatment (70%) (χ(2) = 36.66, p < 0.001). All 9 patients assessed serially during therapy had positive sputum PCR pre-treatment and all became negative during itraconazole treatment.

CONCLUSION

We have shown that isolation of fungus from the airway of severe asthma patients with fungal sensitisation is very common, supporting the hypothesis of a mechanistic link between fungal colonisation and sensitisation.

Non-cystic fibrosis bronchiectasis in children: clinical profile, etiology and outcome

OBJECTIVE

To describe clinical profile, etiology and outcome in children with non-cystic fibrosis bronchiectasis.

METHODS

A chart review of children diagnosed with non-cystic fibrosis bronchiectasis, attending pediatric chest clinic of tertiary care hospital.

RESULTS

The underlying cause was identified in 51 (63.8%) out of 80 children (mean age, 9.6 y). Common causes were post-infectious in 19 (23.8%), suspected primary ciliary dyskinesia in 12 (15%), and allergic bronchopulmonary aspergillosis in 6 (7.5%). One or more complications were observed in 76 (95%) patients; 14 (17.5%) children required surgery and 5 (11.1%) children died.

CONCLUSIONS

Common causes of non-cystic fibrosis bronchiectasis are post infectious and primary ciliary dyskinesia. There is a need to create awareness about early diagnosis of bronchiectasis as it is often delayed.

Diagnostic criteria that can most accurately differentiate allergic bronchopulmonary mycosis from other eosinophilic lung diseases: A retrospective, single-center study

BACKGROUND

Several diagnostic criteria have been proposed to differentiate allergic bronchopulmonary mycosis (ABPM) from asthma, but there have been no studies to establish diagnostic criteria to classify ABPM differently from other eosinophilic lung diseases.

METHODS

We retrospectively investigated both patients with ABPM (n=42) diagnosed by clinical (Rosenberg-Patterson criteria modified to apply to fungi other than Aspergillus spp., with consideration of computed tomography and bronchoscopy findings) or pathological criteria and those with other eosinophilic lung diseases (n=118) to establish elaborate diagnostic criteria for ABPM.

RESULTS

Etiologies of ABPM included fungi other than Aspergillus spp. or unidentified pathogens in 16 patients. Fourteen patients (33.3%) did not have asthma. When the diagnostic cutoff line was set to satisfy six or more primary plus secondary modified Rosenberg-Patterson criteria, ABPM could be diagnosed with good sensitivity, specificity, and positive/negative predictive values (97.6%, 98.3%, 95.3%, and 99.1%, respectively). When the diagnostic criteria were combined with pathological criteria, the values further improved to 100%, 98.3%, 95.5%, and 100%, respectively.

CONCLUSIONS

Our results suggest that these novel criteria offer good sensitivity, specificity, and positive/negative predictive values for the diagnosis and classification of ABPM.

The spectrum of allergic fungal diseases of the upper and lower airways

Fungi cause a wide spectrum of fungal diseases of the upper and lower airways. There are three main phyla involved in allergic fungal disease: (1) Ascomycota (2) Basidiomycota (3) Zygomycota. Allergic fungal rhinosinusitis (AFRS) causes chronic rhinosinusitis symptoms and is caused predominantly by Aspergillus fumigatus in India and Bipolaris in the United States. The recommended treatment approach for AFRS is surgical intervention and systemic steroids. Allergic bronchopulmonary aspergillosis (APBA) is most commonly diagnosed in patients with asthma or cystic fibrosis. Long term systemic steroids are the mainstay treatment option for ABPA with the addition of an antifungal medication. Fungal sensitization or exposure increases a patient's risk of developing severe asthma and has been termed severe asthma associated with fungal sensitivity (SAFS). Investigating for triggers and causes of a patient's asthma should be sought to decrease worsening progression of the disease.

Prospective Evaluation of a New Aspergillus IgG Enzyme Immunoassay Kit for Diagnosis of Chronic and Allergic Pulmonary Aspergillosis

Anti-Aspergillus IgG antibodies are important biomarkers for the diagnosis of chronic pulmonary aspergillosis (CPA) and allergic bronchopulmonary aspergillosis (ABPA). We compared the performance of a new commercial enzyme immunoassay (EIA) (Bordier Affinity Products) with that of the Bio-Rad and Virion\Serion EIAs. This assay is novel in its association of two recombinant antigens with somatic and metabolic antigens of Aspergillus fumigatus In a prospective multicenter study, 436 serum samples from 147 patients diagnosed with CPA (136 samples/104 patients) or ABPA (94 samples/43 patients) and from 205 controls (206 samples) were tested. We obtained sensitivities of 97%, 91.7%, and 86.1%, and specificities of 90.3%, 91.3%, and 81.5% for the Bordier, Bio-Rad, and Virion\Serion tests, respectively. The Bordier kit was more sensitive than the Bio-Rad kit (P < 0.01), which was itself more sensitive than the Virion\Serion kit (P = 0.04). The Bordier and Bio-Rad kits had similar specificity (P = 0.8), both higher than that of the Virion\Serion kit (P = 0.02). The area under the receiver operating characteristic (ROC) curves confirmed the superiority of the Bordier kit over the Bio-Rad and the Virion\Serion kits (0.977, 0.951, and 0.897, respectively; P < 0.01 for each comparison). In a subset analysis of 279 serum samples tested with the Bordier and Bio-Rad kits and an in-house immunoprecipitin assay (IPD), the Bordier kit had the highest sensitivity (97.7%), but the IPD tended to be more specific (71.2 and 84.7%, respectively; P = 0.10). The use of recombinant, somatic, and metabolic antigens in a single EIA improved the balance of sensitivity and specificity, resulting in an assay highly suitable for use in the diagnosis of chronic and allergic aspergillosis.

Diagnostics and susceptibility testing in Aspergillus

Invasive aspergillosis is a major cause of morbidity and mortality in immunosuppressed patients. Early diagnosis and correct antifungal treatment have a direct impact on patient survival. A number of newer diagnostic procedures have been developed as alternatives to conventional microbiological methods. The detection of fungal components, largely antigens and DNA, are used in clinical laboratories to diagnose invasive aspergillosis. Other rapid diagnostic tests have been recently developed with promising results. However, antifungal resistance is becoming an emerging problem. The detection of this resistance is important to administer the proper antifungal agent. This text reviews the novelties on new diagnostics Aspergillus spp.

PROCEDURES

Intrinsic antifungal resistance and mechanisms of secondary resistance to triazoles in A. fumigatus are also reviewed.

Microbial yield from physiotherapy assisted sputum production in respiratory outpatients

BACKGROUND

Sputum is a key diagnostic sample for those with chronic chest conditions including chronic and allergic aspergillus-related disease, but often not obtained in clinic. The objective of this study was to evaluate physiotherapeutic interventions to obtain sputum from those not able to spontaneously produce and the subsequent microbiological result.

METHODS

Sputum samples were collected by physiotherapists from patients attending routine outpatient clinics managing their aspergillus-related diseases who were unable to spontaneously produce. Active Cycle of Breathing Techniques (ACBT) technique was applied first, for 10 min, followed by hypertonic saline induction using a Pari LC plus or Pari Sprint nebuliser, if necessary and deemed safe to do so. Samples processed in the laboratory using standard microbiological techniques for bacterial and fungal culture with the addition of Aspergillus real-time PCR.

RESULTS

Samples were procured from 353 of 364 (97%) patients, 231 (65%) by ACBT and 119 (34%) with administration of hypertonic saline. Three of 125 (2.4%) patients had significant bronchospasm during sputum induction. Sixteen patients' sputum tested positive for Aspergillus culture, contrasting with 82 whose Aspergillus PCR was positive, 59 with a strong signal. PCR improved detection of Aspergillus by 350%. Sputum from 124 (34%) patients cultured other potentially pathogenic organisms which justified specific therapy.

CONCLUSIONS

Physiotherapeutic interventions safely and effectively procured sputum from patients unable to spontaneously produce. The method for sputum induction was well-tolerated and time-efficient, with important microbiological results.

Eosinophilic pneumonias in children: A review of the epidemiology, diagnosis, and treatment

Pediatric eosinophilic pneumonias (EPs) are characterized by a significant infiltration of the alveolar spaces and lung interstitium by eosinophils, with conservation of the lung structure. In developed countries, EPs constitute exceptional entities in pediatric care. Clinical symptoms may be transient (Löffler syndrome), acute (<1 month and mostly <7 days), or chronic (>1 month). Diagnosis relies on demonstration of alveolar eosinophilia on bronchoalveolar lavage, whether or not associated with blood eosinophilia. EPs are a heterogeneous group of disorders divided into: (i) secondary forms (seen mainly in parasitic infections, allergic bronchopulmonary aspergillosis, and drug reactions); and (ii) primary forms (eosinophilic granulomatosis with polyangiitis, hypereosinophilic syndrome, idiopathic chronic eosinophilic pneumonia, and idiopathic acute eosinophilic pneumonia). Despite their rarity, the etiological approach to EP must be well-defined as some causes can be rapidly life-threatening without initiation of the proper treatment. This approach (i) eliminates secondary forms, with comprehensive history taking and minimal biological assessment, (ii) is oriented in primary forms by the acute or chronic setting, and the existence of extrapulmonary symptoms. Treatment of primary forms has traditionally relied on corticosteroids, usually with a dramatic response. Specific treatments or the adjunction of corticosteroid-sparing treatment or immunosuppressors are currently being evaluated in order to improve the prognosis and the side effects associated with corticosteroid treatment in a pediatric setting.

A pilot randomized trial of nebulized amphotericin in patients with allergic bronchopulmonary aspergillosis

BACKGROUND AND AIM

Nebulized amphotericin B (NAB) has been used in the management of acute stage and exacerbations of allergic bronchopulmonary aspergillosis (ABPA). Whether NAB can prevent exacerbations of ABPA is not known. Herein, we evaluate the efficacy and safety of NAB in subjects with ABPA complicating asthma.

METHODS

Consecutive subjects of ABPA with recurrent exacerbations were randomized to receive either NAB plus nebulized budesonide (NEB) or NEB alone. The primary outcome was the time-to-first exacerbation of ABPA. The secondary outcomes were the number of subjects with ABPA exacerbations, ACQ7 scores, lung function, IgE levels, and adverse effects of treatment.

RESULTS

Twenty-one subjects (14 men; mean age, 32.3 years) were randomized to either the NAB (n = 12) or the NEB (n = 9) arm. The baseline characteristics were similar in the two groups. The time-to-first exacerbation was similar in the two groups. At one year, the numbers of patients experiencing exacerbation was significantly lower in the NAB arm (1/12 [8.3%] vs. 6/9 [66.7%]; p = 0.016). The other secondary end points were not different between the two groups. There were no major adverse events leading to discontinuation of any of the study drugs. Three patients experienced bronchospasm after first dose of NAB; however, the subsequent doses were well tolerated.

CONCLUSIONS

NAB seems to be beneficial in decreasing the frequency of exacerbations in patients with ABPA complicating asthma. Larger trials are required to confirm our study results.

Serological diagnosis of allergic bronchopulmonary mycosis: Progress and challenges

Prompt diagnosis of allergic bronchopulmonary mycosis (ABPM) is an important clinical issue in preventing irreversible lung damage. Therefore, a good serological marker for the diagnosis of ABPM is desired in clinical practice. The measurement of IgE antibody to crude Aspergillus fumigatus allergen is considered the first step in screening asthmatic patients for allergic bronchopulmonary aspergillosis (ABPA). However, presence of IgE to A. fumigatus does not always indicate genuine sensitization to A. fumigatus because of cross-reactivity between crude extracts from different fungal sources. The application of molecular-based allergy diagnosis can solve this problem. The specificity of testing can be greatly improved by measuring the IgE antibody to Asp f 1 and f 2, specific allergen components for genuine A. fumigatus allergy. The problem of cross-reactivity between crude fungal extracts is also true for the identification of genuine causal fungi in each ABPM patient. Some patients with ABPM induced by fungi other than Aspergillus may be consistent with ABPA diagnostic criteria because current criteria depend on IgE/IgG reactivity to crude extracts. Accurate identification of genuine causal fungi for ABPM is of clinical importance, considering that clinical presentation, anti-fungal treatment strategies and disease prognosis can be influenced by different causal fungi. The diagnosis of causal fungi can be robustly validated by the confirmation of genuine sensitization to fungi after measuring IgE to specific allergen components, as well as repeated microbiological isolation of the fungi from their airway.

New Commercially Available IgG Kits and Time-Resolved Fluorometric IgE Assay for Diagnosis of Allergic Bronchopulmonary Aspergillosis in Patients with Cystic Fibrosis

Allergic bronchopulmonary aspergillosis (ABPA) is difficult to diagnose; diagnosis relies on clinical, radiological, pathological, and serological criteria. Our aim was to assess the performance of two new commercially available kits and a new in-house assay: an Aspergillus fumigatus enzyme-linked immunosorbent assay (ELISA) IgG kit (Bordier Affinity Products), an Aspergillus Western blotting IgG kit (LDBio Diagnostics), and a new in-house time-resolved fluorometric IgE assay (dissociation-enhanced lanthanide fluorescent immunoassay, or DELFIA) using recombinant proteins from an Aspergillus sp. recently developed by our laboratory for ABPA diagnosis in a retrospective study that included 26 cystic fibrosis patients. Aspergillus fumigatus-specific IgG levels measured by a commercial ELISA kit were in accordance with the level of precipitins currently used in our lab. The ELISA kit could accelerate and help standardize ABPA diagnosis. Aspergillus fumigatus-specific IgE levels measured by ImmunoCAP (Phadia) with A. fumigatus M3 antigen and by DELFIA with a purified protein extract of A. fumigatus were significantly correlated (P < 10(-6)). The results with recombinant antigens glucose-6-phosphate isomerase and mannitol-1-phosphate dehydrogenase were encouraging but must be confirmed with sera from more patients. The DELFIA is an effective tool that can detect specific IgE against more fungal allergens than can be detected with other commercially available tests.

Comparison of six Aspergillus-specific IgG assays for the diagnosis of chronic pulmonary aspergillosis (CPA)

OBJECTIVES

Chronic pulmonary aspergillosis (CPA) is estimated to affect 3 million persons worldwide. Aspergillus-specific IgG is a key component in CPA diagnosis. We aimed to establish the optimal diagnostic cut offs for CPA and the comparative performance of six assays in this context.

METHODS

Sera from 241 patients with CPA and 100 healthy blood donors were tested using five Aspergillus-specific IgG assays plus precipitin testing using Microgen Aspergillus antigens.

RESULTS

Receiver operating characteristic (ROC) curve area under the curve (AUC) results were as follows: ThermoFisher Scientific ImmunoCAP 0.996 (95% confidence interval 0.992-1), Siemens Immulite 0.991 (0.982-1), Serion 0.973 (0.960-0.987), Dynamiker 0.918 (0.89-0.946) and Genesis 0.902 (0.871-0.933). Optimal CPA diagnostic cut-offs were; ImmunoCAP 20 mg/L (96% sensitivity, 98% specificity), Immulite 10 mg/L (96% sensitivity, 98% specificity), Serion 35 U/ml (90% sensitivity, 98% specificity), Dynamiker 65 AU/ml (77% sensitivity, 97% specificity) and Genesis 20 U/ml (75% sensitivity, 99% specificity). The precipitin test was 59% sensitive and 100% specific.

CONCLUSIONS

ImmunoCAP and Immulite were statistically significantly superior to the other assays. Precipitins testing performed poorly. The currently accepted ImmunoCAP cut-off of 40 mg/L appears sub-optimal for CPA diagnosis and may require revision in this context.

Blood basophil activation is a reliable biomarker of allergic bronchopulmonary aspergillosis in cystic fibrosis

The diagnosis of cystic fibrosis (CF) patients with allergic bronchopulmonary aspergillosis (ABPA) is clinically challenging, due to the absence of an objective biological test. Since blood basophils play a major role in allergic responses, we hypothesised that changes in their surface activation pattern discriminate between CF patients with and without ABPA.

We conducted a prospective longitudinal study (Stanford cohort) comparing basophil activation test CD203c levels by flow cytometry before and after activation withAspergillus fumigatusallergen extract or recombinantAspf1 in 20 CF patients with ABPA (CF-ABPA) and in two comparison groups: CF patients withA. fumigatuscolonisation (AC) but without ABPA (CF-AC; n=13) and CF patients without either AC or ABPA (CF; n=12). Patients were tested every 6 months and when ill with pulmonary exacerbation. We also conducted cross-sectional validation in a separate patient set (Dublin cohort).

Basophil CD203c surface expression reliably discriminated CF-ABPA from CF-AC and CF over time. Ex vivostimulation withA. fumigatusextract or recombinantAspf1 produced similar results within the Stanford (p<0.0001) and the Dublin cohorts. CF-ABPA patients were likelier to have elevated specific IgE toA. fumigatusand were less frequently co-infected withStaphylococcus aureus.

Basophil CD203c upregulation is a suitable diagnostic and stable monitoring biomarker of ABPA in CF.

A randomised trial of glucocorticoids in acute-stage allergic bronchopulmonary aspergillosis complicating asthma

Whether use of high-dose steroids in acute-stage allergic bronchopulmonary aspergillosis (ABPA) is associated with superior outcomes is not known. Herein, we compare the efficacy and safety of two glucocorticoid protocols in ABPA.Treatment-naive ABPA subjects randomly received either high-dose or medium-dose oral prednisolone. The primary outcomes were exacerbation rates and glucocorticoid-dependent ABPA after 1 and 2 years, respectively, of treatment. The secondary end-points were composite response rates after 6 weeks, improvement in lung function, time to first exacerbation, cumulative dose and adverse effects.92 subjects (high-dose n=44, medium-dose n=48) were included in the study. The numbers of subjects with exacerbation after 1 year (high-dose 40.9% versus medium-dose 50%, p=0.59) and glucocorticoid-dependent ABPA after 2 years (high-dose 11.4% versus medium-dose 14.6%, p=0.88) were similar in the two groups. Although composite response rates were significantly higher in the high-dose group, improvement in lung function and time to first exacerbation were similar in the two groups. Cumulative glucocorticoid dose and side-effects were significantly higher in the high-dose group.Medium-dose oral glucocorticoids are as effective and safer than high-dose in treatment of ABPA.

Response to pneumococcal polysaccharide vaccination in patients with chronic and allergic aspergillosis

INTRODUCTION

Pneumococcal infection causes significant morbidity in patients with underlying lung disease, and vaccination has been associated with reduced disease rates. Response to vaccination has not been studied in chronic lung conditions characterised by ongoing infection or inflammation like chronic pulmonary aspergillosis (CPA).

METHODS

In a prospective observational study, consecutive patients with CPA, allergic aspergillosis and bronchiectasis attending a national referral centre received pneumococcal 23-valent polysaccharide vaccine (PPV-23) and had pre- and post-vaccination antibody concentrations quantified as part of routine clinical care. Serotype-specific pneumococcal IgG antibodies were quantified for 12 serotypes using a multiplex microsphere assay. A protective response was defined as a level of >1.3μg/mL or a ≥ fourfold rise in concentration for ≥70% of serotypes, pre to post-vaccination. C-reactive protein, Immunoglobulins and mannose binding lectin (MBL) levels were measured and correlated to vaccine response.

RESULTS

A total of 318 patients were enrolled. In vaccine-naïve patients (n=127), the lowest pre-vaccination levels were seen with serotypes 1 and 4 and the highest with serotype 19A. A protective response post-vaccination was seen in 50% of patients. The poorest responses were observed with serotypes 1, 3 and 4. Levels of C-reactive protein did not affect efficacy. Profound MBL deficiency was found in 28.8%; there were no significant differences in response to vaccination in patients with or without MBL deficiency. Post-vaccination serotype-specific concentrations waned gradually, however they were still elevated compared to pre-vaccination after 2-5 years.

CONCLUSIONS

Patients with chronic and allergic aspergillosis exhibited a poor response to PPV-23 vaccination compared to healthy adults. An alternative vaccination strategy or delay of vaccination until their underlying condition is better controlled, e.g. after treatment with antifungals may result in better response.

Utility of IgE (total and Aspergillus fumigatus specific) in monitoring for response and exacerbations in allergic bronchopulmonary aspergillosis

The role of total and specific IgE in monitoring treatment responses in allergic bronchopulmonary aspergillosis (ABPA) remains poorly studied. Here in, we evaluate the utility of total and Aspergillus fumigatus specific IgE in the follow-up of ABPA. Eighty-one consecutive treatment-naïve patients of ABPA (acute stage) with pulmonary infiltrates and bronchiectasis underwent measurement of total and A. fumigatus specific IgE at baseline, after 8 weeks of glucocorticoid therapy, and during exacerbations. There was clinical and radiological improvement after treatment with median decline of total IgE by 51.9%. The total IgE declined by at least 35%, 25% and 20% in 69 (85.2%), 76 (93.6%) and 78 (96.3%) patients, respectively. On the other hand, the A. fumigatus specific IgE increased in 42 (51.9%) subjects, and the mean increase was 1.4%, after 8 weeks. Among 13 patients with exacerbation, 12 (92.3%) had a rise of total IgE by >50%. The A. fumigatus specific IgE increased in only five (38.5%) subjects during exacerbation. Thus, the total IgE is a useful test in monitoring treatment responses in ABPA while A. fumigatus specific IgE has limited utility.

Non Cystic Fibrosis Bronchiectasis

Bronchiectasis is a pathological abnormality of the airways in which there is permanent dilatation and thickening of the airways. Precise incidence/prevalence in India is not known. Recent data suggests that about 1 % young children admitted in a hospital with pneumonia may develop bronchiectasis. Due to significant burden of pneumonia in young children in developing countries including India, it may be a significant problem that is possibly under recognized. Causes of bronchiectasis depend on the burden of respiratory infections and availability of the investigations for identification of the underlying cause. Post infectious causes are common in countries where infections are more common; however, since these countries are usually resource constrained and therefore, are not able to appropriately diagnose the other causes, leading to more than real overrepresentation of infections as a cause. In countries with less of infectious illnesses and good diagnostic facilities, malformations of airways, immune deficiency disorders and primary ciliary dyskinesia are common causes of bronchiectasis. High resolution CT scan of chest confirms the diagnosis. Treatment is supportive care and consists of maintenance of nutrition, airway clearance and antibiotics for exacerbations. Medical treatment is successful in the majority.

Republished: The clinical spectrum of pulmonary aspergillosis

The clinical presentation of Aspergillus lung disease is determined by the interaction between fungus and host. Invasive aspergillosis develops in severely immunocompromised patients, including those with neutropenia, and increasingly in the non-neutropenic host, including lung transplant recipients, the critically ill patients and patients on steroids. A high index of suspicion is required in patients without the classical risk factors as early presentation is usually silent and non-specific, pyrexia uncommon and timely treatment is crucial for survival. Invasive aspergillosis has also been diagnosed in normal hosts after massive exposure to fungal spores. Chronic pulmonary aspergillosis affects patients without obvious immune compromise, but with an underlying lung condition such as COPD or sarcoidosis, prior or concurrent TB or non-tuberculous mycobacterial disease. Aspergillus bronchitis may be responsible for persistent respiratory symptoms in patients with Aspergillus detected repeatedly in sputum without evidence of parenchymal Aspergillus disease, especially in patients with bronchiectasis and cystic fibrosis. Allergic bronchopulmonary aspergillosis affects patients with asthma and cystic fibrosis, and is important to recognise as permanent lung or airways damage may accrue if untreated. Changes in the classification of Aspergillus allergic lung disease have been proposed recently. Cases of extrinsic allergic alveolitis and chronic pulmonary aspergillosis have been observed after Aspergillus exposure. Asymptomatic colonisation of the respiratory tract needs close monitoring as it can lead to clinical disease especially with ongoing immunosuppression. The various syndromes should be viewed as a semicontinuous spectrum of disease and one form may evolve into another depending on the degree of ongoing immunosuppression.

In silico modeling of spore inhalation reveals fungal persistence following low dose exposure

The human lung is constantly exposed to spores of the environmental mould Aspergillus fumigatus, a major opportunistic pathogen. The spectrum of resultant disease is the outcome of complex host-pathogen interactions, an integrated, quantitative understanding of which lies beyond the ethical and technical reach permitted by animal studies. Here we construct a mathematical model of spore inhalation and clearance by concerted actions of macrophages and neutrophils, and use it to derive a mechanistic understanding of pathogen clearance by the healthy, immunocompetent host. In particular, we investigated the impact of inoculum size upon outcomes of single-dose fungal exposure by simulated titrations of inoculation dose, from 10(6) to 10(2) spores. Simulated low-dose (10(2)) spore exposure, an everyday occurrence for humans, revealed a counter-intuitive prediction of fungal persistence (>3 days). The model predictions were reflected in the short-term dynamics of experimental murine exposure to fungal spores, thereby highlighting the potential of mathematical modelling for studying relevant behaviours in experimental models of fungal disease. Our model suggests that infectious outcomes can be highly dependent upon short-term dynamics of fungal exposure, which may govern occurrence of cyclic or persistent subclinical fungal colonisation of the lung following low dose spore inhalation in non-neutropenic hosts.

Development of chronic pulmonary aspergillosis in adult asthmatics with ABPA

BACKGROUND

Chronic pulmonary aspergillosis (CPA) is an occasional complication of allergic bronchopulmonaryaspergillosis (ABPA) but the transition is poorly understood.

METHODS

All patients referred to the UK's National Aspergillosis Centre with CPA between May 2009 and June 2012 were screened with serum total IgE and anti-Aspergillus IgE for a dual diagnosis of ABPA and CPA. Those patients suspected of having both conditions were re-evaluated and their imaging reviewed.

RESULTS

Of 407 referred patients, 42 screened positive and 22 were confirmed as having both ABPA and CPA. Asthma was present from early childhood in 19 (86%), the median interval between ABPA and onset of CPA was 7.5 years; one patient developed ABPA and CPA simultaneously. Aspergillus IgG levels varied from 23 to 771 mg/L, median 82 mg/L. All 22 patients had bronchiectasis. In patients with ABPA, CT typically demonstrated varicose or cystic bronchiectasis primarily affecting segmental and proximal subsegmental upper lobe bronchi. Other findings included mucoid impaction and centrilobular nodules. Radiological changes associated with CPA included pleural thickening which was often bilateral and accentuated by adjacent hypertrophied extrapleural fat, upper lobe volume loss, thick walled apical cavities, some of which contained aspergillomas, and cavitating pulmonary nodules. CPA secondary to ABPA has more subtle radiological appearances than when due to other underlying diseases.

CONCLUSIONS

CPA may complicate ABPA and have distinct radiology features, in addition to bronchiectasis. A novel biomarker is required to anticipate this serious complication, as current serology is not specific enough.

Primary Care of the Patient with Asthma

Obstructive lung disease includes asthma and chronic obstructive pulmonary disease (COPD). Because a previous issue of Medical Clinics of North America (2012;96[4]) was devoted to COPD, this article focuses on asthma in adults, and addresses some topics about COPD not addressed previously. Asthma is a heterogeneous disease marked by variable airflow obstruction and bronchial hyperreactivity. Onset is most common in early childhood, although many people develop asthma later in life. Adult-onset asthma presents a particular challenge in the primary care clinic because of incomplete understanding of the disorder, underreporting of symptoms, underdiagnosis, inadequate treatment, and high rate of comorbidity.

[Infectious pulmonary diseases]

Infektiöse Lungenerkrankungen oder Pneumonien sind die Haupttodesursache innerhalb der Infektionskrankheiten in Deutschland. Hierbei ist die bakterielle Verursachung am häufigsten. Die Form der Entzündung wird meist durch das schädigende Agens bestimmt, jedoch sind häufig verschiedene Reaktionen anzutreffen. Morphologisch kann nur in wenigen Fällen der Erreger konkret bestimmt werden, sodass meist eine zusätzliche mikrobiologische Erregerdiagnostik notwendig ist. Klinisch erfolgt eine Einteilung in ambulant erworbene und nosokomiale Pneumonien, Pneumonien bei Immunsuppression und die Mykobakteriosen. Histologisch ist eine Einteilung gemäß der bevorzugten Ausbreitung in alveoläre und interstitielle bzw. in lobäre und herdförmige Pneumonien möglich.

Antifungal treatment in allergic bronchopulmonary aspergillosis with and without cystic fibrosis: a systematic review

Allergic bronchopulmonary aspergillosis (ABPA) is a rare disease that affects patients with asthma or cystic fibrosis. Its debilitating course has led to the search for new treatments, including antifungals and monoclonal antibodies. To evaluate the efficacy and safety of antifungal treatments in patients with ABPA and either asthma or cystic fibrosis, we performed a systematic review of the literature on the effects of antifungal agents in ABPA using three biomedical databases. Quality assessment was performed using the GRADE methodology and, where appropriate, studies with comparable outcomes were pooled for meta-analysis. Thirty-eight studies - four randomized controlled trials and 34 observational studies - met the eligibility criteria. The antifungal interventions described were itraconazole, voriconazole, posaconazole, ketoconazole, natamycin, nystatin and amphotericin B. An improvement in symptoms, frequency of exacerbations and lung function was reported in most of the studies and was more common with oral azoles. Antifungals also had a positive impact on biomarkers and radiological pulmonary infiltrates, but adverse effects were also common. The quality of the evidence supporting these results was low or very low due to a shortage of controlled studies, heterogeneity between studies and potential bias. Antifungal interventions in ABPA improved patient and disease outcomes in both asthma and cystic fibrosis. However, the recommendation for their use is weak and clinicians should therefore weigh up desirable and undesirable effects on a case-by-case basis. More studies with a better methodology are needed, especially in cystic fibrosis, to increase confidence in the effects of antifungal treatments in ABPA.

Allergic bronchopulmonary aspergillosis in an adult with Kartagener syndrome

Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder resulting from immune responses directed against inhaled Aspergillus fumigatus antigens. It manifests with poorly controlled asthma, fleeting pulmonary opacities and structural lung damage in the form of bronchiectasis. Initially defined in individuals suffering from bronchial asthma and cystic fibrosis, it has also been described in patients with other structural lung disorders such as chronic obstructive pulmonary disease, pulmonary tuberculosis, idiopathic bronchiectasis and others. Kartagener syndrome is a manifestation of primary ciliary dyskinesia characterised by the presence of dextrocardia, bronchiectasis and chronic sinusitis. We report a case of ABPA in an adult suffering from Kartagener syndrome. We also performed a systematic review of the literature on the association between Kartagener syndrome and ABPA.

Antifungals in severe asthma

PURPOSE OF REVIEW

Despite guideline-based treatment, many patients with severe asthma continue to have uncontrolled disease. Fungal allergy is being increasingly recognized in the pathogenesis of severe asthma. Limited data exist on the approach to treatment of fungal asthma. This review summarizes existing evidence on the use of antifungal agents in allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS), and highlights needed areas of future investigation.

RECENT FINDINGS

Recent studies evaluating oral triazole therapy in ABPA appear to support triazole use in a carefully considered clinical setting, whereas studies assessing triazole use in SAFS have yielded mixed results. Despite early encouraging findings that oral triazole use may improve asthma symptoms, stabilize lung function, decrease inhaled and systemic corticosteroid requirements, and alter serum biomarkers, overall data are limited. Appropriate patient selection, as well as choice of the optimal drug, dose, frequency, and duration of therapy, remains poorly defined.

SUMMARY

The role of antifungal therapy in severe asthma remains unclear. Early studies have suggested a possible benefit of some antifungal agents, such as oral triazoles in ABPA and SAFS; however, routine clinical use of these agents in severe asthma without ABPA is not currently recommended. Further research is needed to better delineate the potential utility of antifungal medications in severe asthma and identify the asthma populations who benefit from such treatment.

Allergic fungal airway disease: pathophysiologic and diagnostic considerations

PURPOSE OF REVIEW

Fungal spores are ubiquitously present in indoor and outdoor air. A number can act as aeroallergens in Immunoglobulin E (IgE)-sensitized individuals and some thermotolerant fungi germinate in the lung where they can cause a combined allergic and infective stimulus leading to a number of clinical presentations characterized by evidence of lung damage. We discuss which biomarkers are useful in helping to guide diagnosis, prognosis and treatment of allergic fungal airway disease (AFAD).

RECENT FINDINGS

Diagnostic biomarkers, such as specific IgEs and fungal culture, for AFAD are limited by sensitivity, although this may be improved with novel agents such as specific IgEs to fungal components and quantitative PCR. Total IgE and hypereosinophilia are nonspecific and do not clearly relate to disease activity. High attenuation mucus and proximal bronchiectasis are specific, albeit insensitive markers of AFAD. Biomarkers that predict prognosis and treatment response are yet to be defined.

SUMMARY

This review summarizes the fungi involved and the current debate regarding the diagnostic criteria to define fungal-associated lung disease. We advocate the phasing out of the term allergic bronchopulmonary aspergillosis and the use of a more inclusive term such as AFAD, together with a more liberal set of criteria based largely on IgE sensitization to thermotolerant fungi, which identifies those patients at risk of developing lung damage.

Developments in the field of allergy in 2013 through the eyes of Clinical and Experimental Allergy

2013 was another exciting year for allergy in general and Clinical and Experimental Allergy in particular. In the field of asthma and rhinitis, there continued to be a focus on heterogeneity and phenotypes with increasing use of biostatistical techniques to determine clusters of similar populations. Obesity- and aspirin-associated disease are intriguing associations with asthma which were explored in a number of papers. We published a number of excellent papers on mechanisms of airway inflammation and how this relates to physiology, pathology, genetics and biomarkers in both human and experimental model systems. In terms of mechanisms, there is less on individual cell types in allergic disease at the moment, but the immunology of allergic disease continued to fascinate our authors. Another area that was popular both in the mechanisms and in the epidemiology sections was early life events and how these lead to allergic disease, with an increasing focus on the role of the microbiome and how this influences immune tolerance. In the clinical allergy section, oral immunotherapy for food allergy is clearly a major topic of interest at the moment as was in vitro testing to distinguish between sensitization and allergic disease. There was less on inhalant allergy this year, but a good representation from the drug allergy community including some interesting work on non-IgE-mediated mechanisms. In the allergen section, important new allergens continue to be discovered, but the major focus as in the last couple of years was on working out how component-resolved approaches can improve diagnosis and management of food and venom allergy.

Diagnosis of allergic bronchopulmonary aspergillosis: a case-based approach

Allergic bronchopulmonary aspergillosis is a pulmonary disease occurring in patients with asthma or cystic fibrosis, consequent to a dysregulated immune response to inhaled Aspergillus conidia. The usual presentation is with poorly controlled asthma. Patients may also present with expectoration of mucus plugs, hemoptysis, constitutional symptoms and radiological opacities. Patients may experience smoldering lung destruction despite well-controlled asthma. With emerging data, the diagnostic criteria transcribed by an International Expert Committee in 2013 are the latest evidence-based guidelines. Herein, we utilize a case-based approach to elaborate on the diagnosis of this disease. The review intends to provide a lucid understanding of the diagnostic process for the expert as well as the primary physician, involved in management of this enigmatic disorder.

Aetiology and clinical characteristics of patients with bronchiectasis in a Chinese Han population: A prospective study

BACKGROUND AND OBJECTIVE

Bronchiectasis is a chronic respiratory disease with diverse causes that may differ in clinical features and thus treatment options. However, few large-scale studies on the aetiology of bronchiectasis are currently available. This study aims to determine aetiology and clinical features of bronchiectasis in a Chinese Han population.

METHODS

This prospective study enrolled adult patients diagnosed with bronchiectasis as confirmed by high-resolution computed tomography at five general hospitals in Shandong from January 2010 to August 2014. Causes of bronchiectasis were sought by analysis of clinical history and auxiliary examinations (including serum immunoglobulin determination, saccharin test, Aspergillus skin prick test, autoantibody detection and electronic bronchoscopy).

RESULTS

A total of 476 adult patients with bronchiectasis were included, and all patients were of Chinese Han ethnicity. Idiopathic (66.0%) was the most common cause, followed by post-tuberculosis (16.0%). Other uncommon causes included post-infective (3.8%), immunodeficiency (3.8%), allergic bronchopulmonary aspergillosis (4.0%), rheumatic diseases (4.4%) and primary ciliary dyskinesia (0.9%). Patients with post-tuberculosis bronchiectasis had a higher frequency of upper lobe involvement (P < 0.05). Cylindrical bronchiectasis was the most common type of all causes, with varicose bronchiectasis occurring more frequently in post-tuberculosis bronchiectasis and allergic bronchopulmonary aspergillosis (P < 0.05). However, patients with different causes did not differ in lung function and sputum isolation rate of Pseudomonas aeruginosa (P > 0.05).

CONCLUSIONS

In a Chinese Han population in Shandong, idiopathic bronchiectasis is the most common form of bronchiectasis followed by post-tuberculosis bronchiectasis. Patients with different causes differ in distribution and pattern of bronchiectasis on computed tomography.

Eosinophilia in Pulmonary Disorders

Lung disease associated with marked peripheral blood eosinophilia is unusual and nearly always clinically significant. Once recognized, it is generally easy to manage, albeit with long-term systemic corticosteroids. A failure to respond to oral steroids in the context of good compliance suggests a malignant cause for the eosinophilia. An important development is the introduction of antieosinophil therapies, particularly those directed against the interleukin 5 pathway, which is hoped to provide benefit in the full spectrum of eosinophilic lung disease as well as asthma, reducing the burden of side effects and resultant comorbidities.

Antibody testing in aspergillosis--quo vadis?

Humans are constantly exposed to airborne Aspergillus spores. Most develop Aspergillus-specific antibodies by adulthood. Persons with chronic lung disease or Aspergillus airway colonization often have raised levels of Aspergillus-specific immunoglobululin G (IgG). It is not known whether this signifies an increased risk of future aspergillosis.Chronic and allergic forms of pulmonary aspergillosis are estimated to affect over three million people worldwide. Antibody testing is central to diagnosis of these conditions, with raised Aspergillus-specific IgG in chronic pulmonary aspergillosis and raised Aspergillus-specific IgE in allergic aspergillosis. Antibody levels are also used to monitor treatment response in these syndromes. Acute invasive disease is less common. There is a more limited role for antibody testing in this setting as immunosuppression often results in delayed or absent antibody response.Many methods exist to detect Aspergillus-specific antibodies, but there are limited published data regarding comparative efficacy and reproducibility. We discuss the comparative merits of the available tests in the various clinical settings and their suitability for use in the resource-poor settings where the majority of cases of aspergillosis are thought to occur. We summarize the gaps in existing knowledge and opportunities for further study that could allow optimal use of antibody testing in this field.

Performance of serum galactomannan in patients with allergic bronchopulmonary aspergillosis

Few studies have evaluated the performance of serum galactomannan (GM) in patients with allergic bronchopulmonary aspergillosis (ABPA). Herein, we analyse the diagnostic performance of serum GM in ABPA. Consecutive subjects with ABPA and asthma underwent GM estimation using the Platelia assay (Bio-Rad Laboratories). An optical density index of >0.5 was considered positive. One hundred and twenty subjects (70 ABPA, 50 asthma) with a mean (SD) age of 33.0 (13.1) were included in the study. The serum GM antigen was positive in 18 (25.7%) subjects with ABPA compared to 9 (18%) subjects with asthma without ABPA (P = 0.32). The sensitivity of the serum GM antigen test in patients with ABPA was 25.7% [95% confidence intervals (CI), 16-38] while the specificity was 82% (95% CI, 69-91). The positive and negative predictive values were 66.7% (95% CI, 46-84%) and 44.1% (95% CI, 34-55), respectively. The area under the ROC curve was 0.54 (95% CI, 0.44-0.64). The sensitivity increased and the specificity decreased with decreasing the serum GM cutoff, and vice versa. The results of this study suggest that serum GM estimation has a limited role in the diagnostic workup of patients with ABPA.

Prevalence and mechanism of triazole resistance in Aspergillus fumigatus in a referral chest hospital in Delhi, India and an update of the situation in Asia

Aspergillus fumigatus causes varied clinical syndromes ranging from colonization to deep infections. The mainstay of therapy of Aspergillus diseases is triazoles but several studies globally highlighted variable prevalence of triazole resistance, which hampers the management of aspergillosis. We studied the prevalence of resistance in clinical A. fumigatus isolates during 4 years in a referral Chest Hospital in Delhi, India and reviewed the scenario in Asia and the Middle East. Aspergillus species (n = 2117) were screened with selective plates for azole resistance. The isolates included 45.4% A. flavus, followed by 32.4% A. fumigatus, 15.6% Aspergillus species and 6.6% A. terreus. Azole resistance was found in only 12 (1.7%) A. fumigatus isolates. These triazole resistant A. fumigatus (TRAF) isolates were subjected to (a) calmodulin and β tubulin gene sequencing (b) in vitro antifungal susceptibility testing against triazoles using CLSI M38-A2 (c) sequencing of cyp51A gene and real-time PCR assay for detection of mutations and (d) microsatellite typing of the resistant isolates. TRAF harbored TR₃₄/L98H mutation in 10 (83.3%) isolates with a pan-azole resistant phenotype. Among the remaining two TRAF isolates, one had G54E and the other had three non-synonymous point mutations. The majority of patients were diagnosed as invasive aspergillosis followed by allergic bronchopulmonary aspergillosis and chronic pulmonary aspergillosis. The Indian TR₃₄/L98H isolates had a unique genotype and were distinct from the Chinese, Middle East, and European TR₃₄/L98H strains. This resistance mechanism has been linked to the use of fungicide azoles in agricultural practices in Europe as it has been mainly reported from azole naïve patients. Reports published from Asia demonstrate the same environmental resistance mechanism in A. fumigatus isolates from two highly populated countries in Asia, i.e., China and India and also from the neighboring Middle East.

The diagnostic criteria for allergic bronchopulmonary aspergillosis in children with poorly controlled asthma need to be re-evaluated

AIM

The aim of this study was to examine the association between allergic bronchopulmonary aspergillosis (ABPA) and poorly controlled asthma in children and appraise the diagnostic criteria.

METHODS

The study included 100 children with poorly controlled asthma. We diagnosed ABPA using the Aspergillus skin test, pulmonary function test, total and specific immunoglobulin E (IgE) to Aspergillus fumigatus, chest radiograph and high-resolution computed tomography. Patients were diagnosed and classified according to the Rosenberg-Patterson criteria for ABPA. The cut-off value for total serum IgE was calculated by receiver operating characteristics curve analysis.

RESULTS

Of 100 children with poorly controlled asthma, 26 patients were ABPA positive. There was a significant difference in the forced expiratory volume in 1-sec/forced vital capacity ratio between ABPA positive (0.78 ± 0.14) and negative (0.87 ± 0.15) children (p = 0.008). ABPA positive children were categorised as seropositive, central bronchiectasis and other radiological findings. The receiver operating characteristics curve was constructed, and a value of 1200 IU/mL of total IgE was observed, with 88.5% sensitivity and 70.5% specificity.

CONCLUSION

This study showed an association between ABPA and poorly controlled asthma in children and suggests a higher cut-off value of total IgE for the diagnosis of ABPA.