A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is an immunologic pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus. Clinically, a patient presents with chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis. The population prevalence of ABPA is not clearly known, but the prevalence in asthma clinics is reported to be around 13%. The disorder needs to be detected before bronchiectasis has developed because the occurrence of bronchiectasis is associated with poorer outcomes. Because many patients with ABPA may be minimally symptomatic or asymptomatic, a high index of suspicion for ABPA should be maintained while managing any patient with bronchial asthma whatever the severity or the level of control. This underscores the need for routine screening of all patients with asthma with an Aspergillus skin test. Finally, there is a need to update and revise the criteria for the diagnosis of ABPA. This review summarizes the advances in the diagnosis and management of ABPA using a systematic search methodology.

Central airways obstruction due to Aspergillus fumigatus after lung transplantation

Aspergillus fumigatus may affect immunocompromised lung transplant patients in many ways. We report a new pulmonary manifestation of A fumigatus in 3 patients who underwent bilateral lung transplantation. All 3 subjects developed rapid decreases in pulmonary function and were found to have large central airways obstruction with thick plugs of mucus, heavily laden with Aspergillus species. All 3 patients presented with atypical features of Aspergillus infection, but all responded to treatments with either steroids, anti-fungals or both.

Allergic fungal sinusitis: pathophysiology, diagnosis and management

Allergic fungal sinusitis (AFS) is a noninvasive form of fungal rhinosinusitis with an incidence of between 6 and 9% of all rhinosinusitis requiring surgery. Regional variation in incidence has been reported, with the southern and southwestern US particularly endemic. Patients with AFS commonly present with chronic rhinosinusitis with nasal polyps, inhalant atopy, elevated total serum immunoglobulin E (IgE), and sinus-obstructing inspissates of a characteristic extramucosal 'peanut buttery' visco-elastic eosinophil-rich material called 'allergic mucin' that contains sparse numbers of fungal hyphae. Sinus CT is always abnormal, showing findings of chronic rhinosinusitis that often include central areas of increased contrast ('hyperattenuation') within abnormal paranasal sinuses that represent the presence of fungal-containing allergic mucin. AFS has been found to be analogous in several ways to allergic bronchopulmonary aspergillosis (ABPA). Both are chronic inflammatory respiratory tract disorders that are driven by hypersensitivity responses to the presence of small numbers of extramucosal fungi found growing within airway-impacting allergic mucin. AFS allergic mucin typically cultures positive for either dematiaceous fungi such as Bipolaris spicifera or Curvularia lunata, or Aspergillus species such as A. fumigatus, A. flavus or A. niger. As with ABPA, patients have type I immediate hypersensitivity to the etiologic mold in AFS. Further, both AFS and ABPA have been found to have association with specific class II major histocompatibility alleles. Proper diagnosis of AFS and differentiation from the other forms of both noninvasive and invasive fungal rhinosinusitis requires strict adherence to published diagnostic criteria. Medical treatment of AFS has been modeled to an extent after treatment approaches for ABPA that includes the use of postoperative oral corticosteroids and aggressive antiallergic inflammation therapy. The use of follow-up measurements of total serum IgE during treatment of both AFS and ABPA patients can help to monitor disease activity. Future AFS research will lead to further insights into pathogenesis, improved treatments, and ultimately decreases in surgical recurrence rates for this highly recurrent hypertrophic rhinosinusitis disorder.

Specific IgE response to trichophyton and asthma severity

BACKGROUND

Sensitization to Trichophyton, a major dermatophyte, has been associated with asthma. Whether such sensitization is generally associated with the severity of asthma, like other molds such as Alternaria, is unknown.

METHODS

We compared 258 patients with asthma, which was classified by severity as mild (n = 123), moderate (101), or severe (34), and 114 healthy control subjects, with regard to specific IgE titers against Trichophyton rubrum and other common allergens such as mixed molds, house-dust mite, cat dander, dog dander, Japanese cedar pollen, mixed Graminea pollens and mixed weed pollens.

RESULTS

Positive rate of Trichophyton-specific IgE was higher in the patients with moderate asthma (15.8%) than in the control subjects (7.0%, p = 0.04) and patients with mild asthma (4.9%, p < 0.006), and it was also higher in the patients with severe asthma (32.4%) than in control subjects (p = 0.0001), and patients with mild asthma (p < 0.0001) and moderate asthma (p = 0.04), but it did not differ between the control subjects and patients with mild asthma. The positive rates of mixed molds, cat dander, and dog dander were almost invariably higher in patients in all asthma subgroups than in the control subjects but did not differ among patients in the three asthma subgroups. The positive rates of other allergens were not different in all groups. Reanalysis of positive rate of Trichophyton-specific IgE after excluding 52 subjects with positive results for mixed molds showed a similar statistical trend to that of the original cohort. This may negate the potential effect of cross-reactivity to these molds. Multivariate analysis of asthma subgroups identified positive IgE results for Trichophyton as an independent determinant of asthma severity.

CONCLUSIONS

Specific IgE response to Trichophyton may be associated with more severe asthma.

Allergic Fungal Rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is one of the more commonly encountered forms of noninvasive fungal rhinosinusitis, seen in immunecompetent individuals. It is caused by a Gell and Coombs Type I, IgE mediated (and possibly Type III) hypersensitivity reaction to an extramucosal fungal antigen. It bears striking similarities to Allergic Broncho Pulmonary Aspergillosis (ABPA), in terms of pathogenesis as well as treatment. It commonly presents as nasal polyposis. Most current treatment protocols for this condition are based on a combined medical and surgical approach. In this article we have recapitulated the history, epidemiology, etiology, clinical features, diagnostic investigations and treatment protocols for this disease.

Therapeutic drug monitoring for triazoles

PURPOSE OF REVIEW

Invasive fungal infections are a leading cause of morbidity and mortality in immunocompromised patients, and mechanisms to optimize therapeutic outcomes are urgently required. Therapeutic drug monitoring represents an important component for the routine use of the triazoles.

RECENT FINDINGS

Triazoles have revolutionized the prevention and treatment of invasive fungal infections. Increasing data suggest that this class displays important concentration-effect and concentration-toxicity relationships. There has been an increased understanding of the pharmacokinetics and pharmacodynamics of triazoles, and this has facilitated the identification of concentrations (or drug exposures) that are both effective and nontoxic. This review discusses the application of therapeutic drug monitoring to fluconazole, itraconazole, voriconazole and posaconazole.

SUMMARY

Therapeutic drug monitoring represents an important mechanism to optimize the outcome of immunocompromised patients receiving triazoles.

Treatment of allergic bronchopulmonary aspergillosis (ABPA) in CF with anti-IgE antibody (omalizumab)

Allergic bronchopulmonary aspergillosis (ABPA) results from IgE induced pulmonary response to aspergillus species. Recognition and management of ABPA is challenging in cystic fibrosis (CF) patients because changes in symptoms, lung function and chest radiograph are similar to that seen in CF related pulmonary infection. Standard therapy for ABPA includes systemic steroids and adjunctive use of antifungal agents. Little has been published regarding the use of monoclonal anti-IgE antibody in those with ABPA. We report a CF patient with her third exacerbation of ABPA who was treated with monoclonal anti-IgE (omalizumab) antibody; she had unfavorable side effects with prednisone therapy. This therapy resulted in improvement of pulmonary symptoms and lung function not achieved with antibiotics or prednisone alone.

Randomized controlled trial of oral antifungal treatment for severe asthma with fungal sensitization: The Fungal Asthma Sensitization Trial (FAST) study

RATIONALE

Some patients with severe asthma are immunologically sensitized to one or more fungi, a clinical entity categorized as severe asthma with fungal sensitization (SAFS). It is not known whether SAFS responds to antifungal therapy.

OBJECTIVES

To evaluate the response of SAFS to oral itraconazole.

METHODS

Patients with severe asthma sensitized to at least one of seven fungi by skin prick or specific IgE testing were recruited. All had total IgE less than 1,000 IU/ml and negative Aspergillus precipitins. They were treated with oral itraconazole (200 mg twice daily) or placebo for 32 weeks, with follow-up for 16 weeks.

MEASUREMENTS AND MAIN RESULTS

The primary end point was change in the Asthma Quality of Life Questionnaire (AQLQ) score, with rhinitis score, total IgE, and respiratory function as secondary end points. Fifty-eight patients were enrolled, of whom 41% had been hospitalized in the previous year. Baseline mean AQLQ score was 4.13 (range, 1-7). At 32 weeks, the improvement (95% confidence interval) in AQLQ score was +0.85 (0.28, 1.41) in the antifungal group, compared with a -0.01 (-0.43, 0.42) change in the placebo group (P = 0.014). Rhinitis score improved (-0.43) in the antifungal, and deteriorated (+0.17) in the placebo group (P = 0.013). Morning peak flow improved (20.8 L/minute, P = 0.028) in the antifungal group. Total serum IgE decreased in the antifungal group (-51 IU/ml) but increased in placebo group (+30 IU/ml) (P = 0.001). No severe adverse events were observed, but seven patients developed adverse events requiring discontinuation, five in the antifungal group.

CONCLUSIONS

SAFS responds to oral antifungal therapy as judged by large improvements in quality of life in about 60% of patients.

Eosinophilic Lung Disease

Eosinophilic lung diseases represent a group of disorders in which lung infiltrates seen on a chest radiograph, may or may not be accompanied by peripheral blood eosinophilia. The causes are varied, and range from drug ingestion, parasite or fungal infection, or else, may be idiopathic. The clinical manifestation of these disorders may be mild or severe, depending on the underlying condition. A full history and examination, along with radiological imaging, bronchoscopy, and serological tests are useful in reaching a diagnosis. Treatment with corticosteroids usually results in a good clinical outcome, if the diagnosis is suspected and made early. Early treatment with high dose corticosteroids may be life saving in some patients, whilst other patients require prolonged and sometimes recurrent courses of corticosteroids, due to the chronic relapsing nature of their condition.

Case report: allergic bronchopulmonary aspergillosis and allergic fungal sinusitis successfully treated with voriconazole

Allergic bronchopulmonary aspergillosis and allergic fungal sinusitis are closely related disorders that rarely present in the same individual. The mainstay of treatment for allergic bronchopulmonary aspergillosis is systemic corticosteroids. Itraconazole is used as adjunctive therapy in refractory cases. Allergic fungal sinusitis requires initial sinus surgery followed by systemic steroids. Antifungal therapy has not proven to be beneficial in allergic fungal sinusitis. We report a case of concomitant allergic bronchopulmonary aspergillosis and allergic fungal sinusitis that was refractory to standard therapy but had dramatic clinical response following treatment with voriconazole.

Allergic fungal sinusitis associated with allergic bronchopulmonary aspergillosis: an uncommon sinobronchial allergic mycosis

BACKGROUND

The identification of allergic fungal sinusitis (AFS) is still controversial and much more recent than that of allergic bronchopulmonary aspergillosis (ABPA). Their association has been reported very rarely in the literature.

METHODS

The aim of this study was to present a review of 6 cases of AFS associated with ABPA from a series of 12 cases of AFS and to compare AFS associated with ABPA and isolated AFS.

RESULTS

All cases of AFS presented with chronic rhinosinusitis. The six cases with AFS and ABPA were atopic, asthmatic, with pulmonary infiltrates (five cases), central bronchiectasis (four cases), and both (three cases). The mycological and immunoallergological features of isolated AFS and AFS associated with ABPA were similar: eosinophilic allergic mucin with noninvasive fungi hyphae, high levels of blood eosinophils, total IgE, specific IgE, IgG, and positive skin tests to Aspergillus. The association of AFS and ABPA was concomitant (two cases) or remote in time (four cases). The treatment with oral corticosteroids and sinus surgery (six cases) associated with antifungal drugs (four cases) led to resolution in three cases, considerable improvement in one case, and therapeutic failure in two cases (follow-up longer than 5 years in all cases).

CONCLUSION

Independently of the signs linked to the organs involved (sinuses and bronchi) the mycological and immunoallergological features were similar for AFS and AFS associated with ABPA. AFS and ABPA can be isolated or associated in a sinobronchial allergic

[Refractory asthma: diagnosing allergic bronchopulmonary aspergillosis]

Allergic bronchopulmonary aspergillosis (ABPA) results from a twofold mechanism: Th2-like hypersensitivity reaction and bronchial colonization by Aspergillus fumigatus. This relatively rare disease occurs in immunocompetent patients in two very different situations: refractory asthma and cystic fibrosis. Diagnosis in asthma patients is relatively easy; it is based on the association of several criteria: clinical (recurrent exacerbations despite adequate therapy and a positive A. fumigatus skin prick-test), laboratory (inconsistent blood eosinophilia, high serum levels of total IgE, presence of A. fumigatus-specific IgE and IgG) and radiological (mainly central bronchiectasis, sometimes transitory pulmonary infiltrates). Diagnosis is more difficult in patients with cystic fibrosis because of the similarity of their various criteria. Long-term prognosis is good in the early stages of the illness, although the natural history and course of the disease are not fully understood. Early diagnosis and active screening for exacerbations are recommended to prevent bronchiectasis and progression to end-stage lung disease. Two drugs have shown their efficacy in treating ABPA: corticosteroids and itraconazole. They are recommended in acute exacerbations and should not be used as long-term therapy, except in corticosteroid-dependent asthma and in some cases of cystic fibrosis.

Advances in management of paranasal sinus aspergillosis

Surgery remains the treatment of choice for mycetoma of the paranasal sinuses. Itraconazole has a useful role in reducing both the amount of surgery required and the amount of peri-operative bleeding in allergic aspergillosis, and continuing its use post-operatively for six weeks appears to reduce the recurrence rate (although a case–control study is required to validate this observation). In chronic invasive aspergillosis, itraconazole alone appears to be curative, although liver function tests should be monitored and other interactions considered. Imaging is required to monitor resolution; remineralisation occurs after approximately six months. In fulminant aspergillosis, radical surgery and amphotericin B continue to be the treatments of choice. This review discusses the management of aspergillosis of the paranasal sinuses, and in particular the role of itraconazole antifungal therapy.

A d-optimal designed population pharmacokinetic study of oral itraconazole in adult cystic fibrosis patients

AIM

The primary objective of the study was to estimate the population pharmacokinetic parameters for itraconazole and hydroxy-itraconazole, in particular, the relative oral bioavailability of the capsule compared with solution in adult cystic fibrosis patients, in order to develop new dosing guidelines. A secondary objective was to evaluate the performance of a population optimal design.

METHODS

The blood sampling times for the population study were optimized previously using POPT v.2.0. The design was based on the administration of solution and capsules to 30 patients in a cross-over study. Prior information suggested that itraconazole is generally well described by a two-compartment disposition model with either linear or saturable elimination. The pharmacokinetics of itraconazole and the metabolite were modelled simultaneously using NONMEM. Dosing schedules were simulated to assess their ability to achieve a trough target concentration of 0.5 mg ml(-1).

RESULTS

Out of 241 blood samples, 94% were taken within the defined optimal sampling windows. A two-compartment model with first order absorption and elimination best described itraconazole kinetics, with first order metabolism to the hydroxy-metabolite. For itraconazole the absorption rate constants (between-subject variability) for capsule and solution were 0.0315 h(-1) (91.9%) and 0.125 h(-1) (106.3%), respectively, and the relative bioavailability of the capsule was 0.82 (62.3%) (confidence interval 0.36, 1.97), compared with the solution. There was no evidence of nonlinearity. Simulations from the final model showed that a dosing schedule of 500 mg twice daily for both formulations provided the highest chance of target success.

CONCLUSION

The optimal design performed well and the pharmacokinetics of itraconazole and hydroxy-itraconazole were described adequately by the model. The relative bioavailability for itraconazole capsules was 82% compared with the solution.

Allergic bronchopulmonary aspergillosis: a US perspective

PURPOSE OF REVIEW

The present article is an update of allergic bronchopulmonary aspergillosis. Although a rare condition, allergic bronchopulmonary aspergillosis does affect a number of patients with asthma and cystic fibrosis. Prompt recognition and treatment of the disease is critical to improving patient outcomes.

RECENT FINDINGS

There is currently much active research being performed in the area of allergic bronchopulmonary aspergillosis. Fascinating insights are being made into the pathophysiology and genetics of the disease. Additionally, research is ongoing on the use of recombinant Aspergillus allergens as an aid to the diagnosis of allergic bronchopulmonary aspergillosis.

SUMMARY

These new insights into the genetics and pathophysiology of allergic bronchopulmonary aspergillosis and the development of these new diagnostic techniques could ultimately lead to improved patient treatment. These areas form an important basis for further research.

Aspergillosis: spectrum of disease, diagnosis, and treatment

Infections by Aspergillus species present a particular challenge. The organism, which is ubiquitous in the environment, causes allergic disease in otherwise healthy individuals and devastating disease in the immunosuppressed. This article examines the range of infections caused by Aspergillus species, the challenges of diagnosis, and current treatment options.

Spectrum of noninfectious health effects from molds

Molds are multicellular fungi that are ubiquitous in outdoor and indoor environments. For humans, they are both beneficial (for the production of antimicrobial agents, chemotherapeutic agents, and vitamins) and detrimental. Exposure to mold can occur through inhalation, ingestion, and touching moldy surfaces. Adverse health effects may occur through allergic, infectious, irritant, or toxic processes. The cause-and-effect relationship between mold exposure and allergic and infectious illnesses is well known. Exposures to toxins via the gastrointestinal tract also are well described. However, the cause-and-effect relationship between inhalational exposure to mold toxins and other untoward health effects (eg, acute idiopathic pulmonary hemorrhage in infants and other illnesses and health complaints) is controversial and requires additional investigation. In this report we examine evidence of fungal-related illnesses and the unique aspects of mold exposure to children. Mold-remediation procedures are also discussed.

Differential diagnosis of eosinophilic chronic rhinosinusitis

Eosinophilic chronic rhinosinusitis (ECRS) encompasses a wide variety of etiologies. To date, a unifying pathophysiologic mechanism remains elusive. Eosinophilia is frequently, but not exclusively, caused by immunoglobulin (Ig)E-mediated hypersensitivity and is dominated by the associated cytokine milieu of Th2 inflammation. The provisional subcategories of ECRS include superantigen-induced eosinophilic chronic rhinosinusitis, allergic fungal sinusitis, nonallergic fungal eosinophilic chronic rhinosinusitis, and aspirin-exacerbated eosinophilic chronic rhinosinusitis. Within each subcategory, recent findings supporting distinct mechanisms that promote eosinophilic infiltration are presented, and, therefore, targeted therapeutic interventions with specific antibacterial, antifungal, or immune modulation may be indicated.

Mucoid impaction: an unusual form of allergic bronchopulmonary aspergillosis in a patient with cystic fibrosis

We reported a child with cystic fibrosis (CF) who developed mucoid impaction related to allergic bronchopulmonary aspergillosis (ABPA). This is the first reported case of mucoid impaction related to ABPA in CF described to date in the literature. The case was successfully treated by corticosteroids and itraconazole therapy, but relapsed 6 months later. During exacerbation therapy, cataract formation complicated the corticosteroid treatment. We want to emphasize that 6-months therapy may be inadequate for the treatment of ABPA, and it is important to monitor for possible complications of corticosteroids therapy.

Bronchiectasis

Bronchiectasis is generally classified into cystic fibrosis and non-cystic fibrosis bronchiectasis. This review article describes non-cystic fibrosis bronchiectasis in adults. Bronchiectasis can be considered a heterogeneous condition characterized by irreversible airway dilatation with chronic bronchial infection/inflammation. It remains a common condition and is a major cause of respiratory morbidity. Many factors are associated with bronchiectasis, but most commonly patients will have idiopathic disease. Important clinical findings include chronic productive cough, rhinosinusitis, fatigue and bi-basal crackles. Patients have usually had symptoms for many years. Diagnosis is confirmed by high-resolution computed tomography scanning using standardized criteria. Spirometry shows moderate airflow obstruction and there is a high prevalence of bronchial hyperreactivity. The most common pathogens are non-typeable Haemophilus influenzae and Pseudomonas aeruginosa. There may be considerable overlap with other chronic airway diseases. Treatment regimens are still not well defined. Patients tend to have ongoing symptoms and decline in respiratory function despite treatment.

Critique of trials in allergic bronchopulmonary aspergillosis and fungal allergy

Treatment of allergic bronchopulmonary aspergillosis (ABPA) emerged from uncontrolled published series of patients on prolonged oral glucocorticosteroids. Oral steroids remain the mainstay of treatment, but dose regime and duration have never been standardized. Oral steroids are problematic due to frequency of relapse, lack of steroid action on airway fungal burden and toxicities. Prospective randomized double-blind placebo-controlled trials of inhaled corticosteroids (n=1) or oral itraconazole (n=2) in patients with asthma and ABPA have shown efficacy for the latter drug only. Itraconazole is an effective steroid-sparing agent with anti-inflammatory aspects. Use of inhaled budesonide with itraconazole can lead to adrenal suppression due to inhibition of hepatic cytochrome P450. Despite combined use of oral steroids and itraconazole in ABPA, relapses and steroid dependence or toxicity have led to examination of alternative agents in uncontrolled case reports and series. Reports of nebulized amphotericin B in several patients with cystic fibrosis (CF) and ABPA suggest a potential benefit. Voriconazole has also been used with some success but also some toxicity. Both itraconazole and voriconazole have also been used in some CF-ABPA patients as monotherapy with mixed results. A recent report described treatment of refractory CF-ABPA with monthly high-dose intravenous (IV) methylprednisolone, also with mixed results. No controlled trials of voriconazole, inhaled amphotericin, or IV pulse steroids have been published. Future studies should focus on controlled trials of antifungal and immunomodulatory agents since conventional steroid therapy remains problematic.

Optimal design for model discrimination and parameter estimation for itraconazole population pharmacokinetics in cystic fibrosis patients

Optimal sampling times are found for a study in which one of the primary purposes is to develop a model of the pharmacokinetics of itraconazole in patients with cystic fibrosis for both capsule and solution doses. The optimal design is expected to produce reliable estimates of population parameters for two different structural PK models. Data collected at these sampling times are also expected to provide the researchers with sufficient information to reasonably discriminate between the two competing structural models.

Allergic bronchopulmonary aspergillosis in paediatric cystic fibrosis patients

Allergic bronchopulmonary aspergillosis (ABPA) is a severe complication in children, adolescents and adults with cystic fibrosis (CF), the prevalence of which ranges from 6-25%. The disease is the result of the colonisation of the respiratory tract by fungi of the genus Aspergillus, commonly Aspergillus fumigatus, and subsequent host sensitisation to fungal antigens, accompanied by a Th2 CD4 type response mediated by the production of specific IgE. The consequent inflammatory and obstructive bronchopulmonary injury can progress to fibrosis. The diagnosis should be considered early in patients with CF who show wheezing, transient pulmonary infiltrates and reduced lung function. The objective diagnosis is not straightforward because of overlapping clinical and radiological signs, particularly the progression of bronchiectasis. Specific criteria are needed for the diagnosis of ABPA in patients with CF, such as those proposed by the Cystic Fibrosis Foundation. The study of specific IgE against recombinant antigens of A. fumigatus has contributed to the early diagnosis of ABPA with high sensitivity and specificity. The technique has also shown promise in the follow-up of patients after steroid therapy and the early detection of recurrences. Treatment consists of long-term systemic corticosteroid usage, the monitoring of their adverse effects, and of the measurement of total serum IgE levels. The concomitant use of oral itraconazole seems to promote a better control of the disease and to reduce the duration of systemic steroid therapy but its use continues to be controversial. Controlled studies involving larger numbers of patients are necessary if we are to better understand the management of ABPA.

[Allergy-related hypereosinophilia]

Hypereosinophilia in the blood and tissues is one of the main characteristics of the pathophysiology of allergic disease. CD4+ T cells polarized to a Th2 phenotype mediate inflammatory disorders; cytokines produced by Th2, including IL-4, IL-5, and IL-13, drive the cardinal features of the disease. Recent human experiments indicate that eosinophils may control the bronchial remodeling that occurs in asthma. Eosinophils are a rich source of fibrogenic factors, particularly TGF-ss. Atopy is defined by abnormal IgE production in response to an allergen (an antigen that is then designated an allergen). Allergy combines pre-existent sensitization (atopy) with various symptoms - cutaneous, ENT, respiratory, or digestive. Atopy is diagnosed primarily by cutaneous skin-prick tests and the new multi-allergen blood test. A diagnosis of allergy requires the presence of symptoms and justifies workups for asthma, rhinitis, food allergies, or atopic dermatitis.

Pulse intravenous methylprednisolone for resistant allergic bronchopulmonary aspergillosis in cystic fibrosis

Allergic bronchopulmonary aspergillosis (ABPA) results from a hypersensitivity response to Aspergillus fumigatus. It is seen in a number of chronic respiratory conditions, particularly in association with cystic fibrosis (CF). Oral corticosteroids and itraconazole represent the mainstay of treatment. There is evidence for the use of pulse methylprednisolone in other respiratory conditions as well as a number of inflammatory conditions. This is the first reported use of pulse intravenous methylprednisolone in the treatment of ABPA in CF. We present the clinical course of four children with CF and severe ABPA, in whom pulse methyprednisolone was used to manage the disease because of relapses or marked side effects on high-dose oral corticosteroids. Methylprednisolone pulses achieved disease control in 3 of the 4 children. However, troublesome side effects were experienced, in some cases necessitating discontinuation of therapy. Pulse methylprednisolone may represent a treatment option for children with CF and ABPA, where ABPA fails to respond adequately to routine therapy.

[Allergic fungal sinusitis and allergic broncho-pulmonary aspergillosis: a fortuitous association or a nosological rhino-bronchial entity?]

INTRODUCTION

The identification of allergic fungal sinusitis (AFS) is much more recent than that of allergic broncho-pulmonary aspergillosis (ABPA) and may still be incomplete and controversial. Their association has been only rarely reported in the literature. Is it a matter of a fortuitous association or of a well defined and/or new nosological rhino-bronchial entity?

METHODS

A retrospective study was undertaken from a series of 10 cases of AFS with 4 cases associated with ABPA and fulfilling all the diagnostic criteria described in the literature.

RESULTS

The association of AFS and ABPA may be concomitant (2 cases) or not (2 cases) with a possible time lag of several years between the onset of naso-sinal and broncho-pulmonary disease, even after recovery from the original episode. Treatment comprising steroids, endoscopic surgery (4 cases) combined with anti-fungal drugs (2 cases), led to resolution (2 cases), a considerable improvement (1 case) and therapeutic failure in 1 case (follow up longer than 4 years in all cases).

CONCLUSION

The association, concomitant or remote in time, of AFS and ABPA emphasises the unity of the upper and lower airways as well as the pathophysiological relationship between these two fungal respiratory diseases. The prevalence of this association remains low and the treatment is not standardised.

Chronic Cough Due to Bronchiectasis

BACKGROUND

Bronchiectasis is a condition that is characterized by the permanent dilation of bronchi with destruction of elastic and muscular components of their walls, usually due to acute or chronic infection. The cardinal symptom is a chronic productive cough.

METHODS

Review of articles cited in the systematic literature search, along with others found in Ovid MEDLINE and the Cochrane Library (including the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trial Register, and the Database of Abstracts of Reviews of Effectiveness) from 1966 through 2003.

RESULTS/CONCLUSIONS

High-resolution CT scanning of the chest is the preferred means of establishing the diagnosis of bronchiectasis. With the increasing use of antibiotics in the treatment of childhood infection in the last several decades, an increasing percentage of patients with bronchiectasis now have an underlying disorder that predisposes them to chronic or recurrent infection. These include cystic fibrosis, common variable immunodeficiency, HIV infection, primary ciliary dyskinesia, allergic bronchopulmonary aspergillosis, and chronic Mycobacterium avium complex infection. A variety of agents have been used to improve cough effectiveness and prevent infectious exacerbations in patients with bronchiectasis, with variable results. Chest physiotherapy offers a modest benefit in increasing sputum volume, but its long-term effectiveness is unknown. Selected patients with localized idiopathic bronchiectasis that causes intolerable symptoms despite maximal medical therapy should be offered treatment with surgery. Patients with exacerbations of bronchiectasis should be given antibiotics, with the choice of agents depending on the likely causative pathogens.

Future Directions in the Clinical Management of Cough

OBJECTIVES

To impart a call for further research into the identified domains of particular interest in the etiology, management, and treatment of cough.

DESIGN/METHODOLOGY

A literature review was performed using the search term "cough" in PubMed between 1983 and 2004. The final draft of this guideline was reviewed, in addition to recent studies on cough, and suggestions provided by the authors were collated into a definitive inventory of specific areas in which the lack of quality evidence encumbered the development of clinically relevant evidence-based recommendations.

RESULTS/CONCLUSIONS

Although our understanding of the causes and optimal management of chronic cough have significantly increased over the past 25 years, further research remains to be done on this common symptom. This is reflected by the generally low level of evidence for many of the recommendations in these guidelines. Research is particularly needed on the optimal treatment of postinfectious cough, how to distinguish acute bronchitis from other conditions, how to reliably diagnose and treat cough due to gastroesophageal reflux disease, clearly identifying a role for nonpharmacologic protussive treatment modalities in diseases associated with an increased production of bronchial secretions, determining how often cough in patients with interstitial lung disease is due to conditions other than these, establishing the spectrum and frequency of causes of chronic cough in the immunocompromised hosts, and better characterizing psychogenic cough. Further studies are also needed on methods for the assessment of cough, in particular, noninvasive measures of airway inflammation, and pharmacotherapy. It should be determined how often unexplained cough (previously referred to as idiopathic cough) is due to the use of non-evidence-based guidelines or to environmental causes, and assessed whether an empiric, integrative approach of diagnosing chronic cough leads to better outcomes, including cost-effectiveness, than routine testing. While much work has been done on chronic cough, we need studies on the spectrum and frequency of acute and subacute coughs.

Voriconazole therapy in children with cystic fibrosis

BACKGROUND

There is increasing evidence for the efficacy of the antifungal voriconazole, particularly in immunosuppression. We describe our experience of using voriconazole in children with CF.

METHODS

We performed a retrospective case note review of children with CF treated with voriconazole in a single centre over an 18 month period.

RESULTS

A total of 21 children aged 5 to 16 years (median 11.3) received voriconazole for between 1 and 50 (22) weeks. Voriconazole was used as monotherapy in 2 children with recurrent allergic bronchopulmonary aspergillosis (ABPA); significant and sustained improvements in clinical and serological parameters for up to 13 months were observed, without recourse to oral steroids. Voriconazole was used in combination with an immunomodulatory agent in a further 11 children with ABPA, with significant improvement in pulmonary function and serology. 8 children without ABPA but who had recurrent Aspergillus fumigatus isolates and increased symptoms also received voriconazole; this group did not improve with treatment. Adverse effects occurred in 7 children (33%: photosensitivity reaction 3, nausea 2, rise in hepatic enzymes 1, hair loss 1).

CONCLUSIONS

Voriconazole may be a useful adjunctive therapy for ABPA in CF. Voriconazole monotherapy appears to be an alternative treatment strategy when oral corticosteroids may not be suitable.