Serum immunoglobulin levels in pulmonary allergic aspergillosis and certain other lung diseases, with special reference to immunoglobulin E

Evaluation of the LDBio Aspergillus ICT lateral flow assay for serodiagnosis of allergic bronchopulmonary aspergillosis

BACKGROUND

Early recognition and diagnosis of allergic bronchopulmonary aspergillosis (ABPA) is critical to improve patient symptoms, and antifungal therapy may prevent or delay progression of bronchiectasis and development of chronic pulmonary aspergillosis.

OBJECTIVE

A recently commercialized lateral flow assay (Aspergillus ICT) (LDBio Diagnostics, Lyons, France) detects Aspergillus-specific antibodies in <30 minutes, requiring minimal laboratory equipment. We evaluated this assay for diagnosis of ABPA compared to diseased (asthma and/or bronchiectasis) controls.

METHODS

ABPA and control sera collected at the National Aspergillosis Centre (Manchester, UK) and/or from the Manchester Allergy, Respiratory and Thoracic Surgery research biobank were evaluated using the Aspergillus ICT assay. Results were read both visually and digitally (using a lateral flow reader). Serological Aspergillus-specific IgG and IgE, and total IgE titres were measured by ImmunoCAP.

RESULTS

For 106 cases of ABPA versus all diseased controls, sensitivity and specificity for the Aspergillus ICT were 90.6% and 87.2%, respectively. Sensitivity for 'proven' ABPA alone (n = 96) was 89.8%, and 94.4% for 'presumed' ABPA (n = 18). 'Asthma only' controls (no bronchiectasis) and 'bronchiectasis controls' exhibited 91.4% and 81.7% specificity, respectively. Comparison of Aspergillus ICT result with Aspergillus-specific IgG and IgE titres showed no evident immunoglobulin isotype bias. Digital measurements displayed no correlation between ImmunoCAP Aspergillus-specific IgE level and ICT test line intensity.

CONCLUSIONS

The Aspergillus ICT assay exhibits good sensitivity for ABPA serological screening. It is easy to perform and interpret, using minimal equipment and resources; and provides a valuable simple screening resource to rapidly distinguish more serious respiratory conditions from Aspergillus sensitization alone.

Current Approach in the Diagnosis and Management of Allergic Bronchopulmonary Aspergillosis in Children With Cystic Fibrosis

Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder characterized by a hypersensitivity reaction to Aspergillus fumigatus, and almost always seen in patients with cystic fibrosis (CF) and asthma. Fungal hyphae leads to an ongoing inflammation in the airways that may result in bronchiectasis, fibrosis, and eventually loss of lung function. Despite the fact that ABPA is thought to be more prevalent in CF than in asthma, the literature on ABPA in CF is more limited. The diagnosis is challenging and may be delayed because it is made based on a combination of clinical features, and radiologic and immunologic findings. With clinical deterioration of a patient with CF, ABPA is important to be kept in mind because clinical manifestations mimic pulmonary exacerbations of CF. Early diagnosis and appropriate treatment are important in preventing complications related to ABPA. Treatment modalities involve the use of anti-inflammatory agents to suppress the immune hyperreactivity and the use of antifungal agents to reduce fungal burden. Recently, in an effort to treat refractory patients or to reduce adverse effects of steroids, other treatment options such as monoclonal antibodies have started to be used. Intensive research of these new agents in the treatment of children is being conducted to address insufficient data.

Allergic bronchopulmonary aspergillosis in asthma: epidemiological, clinical and therapeutic issues

Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder caused by immunologic reactions to antigens released by Aspergillus fumigatus, a ubiquitous fungi colonizing the tracheobronchial tree of asthmatic patients. The clinical presentation is usually poorly controlled asthma, recurrent pulmonary opacities and bronchiectasis. The prevalence of ABPA in asthma clinics may be as high as 13% with a global burden of almost 5 million patients. A. fumigatus-specific IgE level is the most sensitive test in diagnosis of ABPA, and all asthmatic patients should be routinely screened with A. fumigatus-specific IgE levels for early diagnosis. The goals of managing ABPA include control of asthma, prevention and treatment of acute exacerbations, and preventing the development or progression of bronchiectasis. Glucocorticoids are the treatment of choice with itraconazole reserved for those with recurrent exacerbations and glucocorticoid-dependent disease. There is a dire need for newer treatment approaches including oral antifungal agents and immunomodulatory therapy.

Fungal rhinosinusitis: what every allergist should know

The interaction between fungi and the sinonasal tract results in a diverse range of diseases with an equally broad spectrum of clinical severity. The classification of these interactions has become complex, and this review seeks to rationalize and simplify the approach to fungal diseases of the nose and paranasal sinuses. These conditions may be discussed under two major headings: non-invasive disease (localized fungal colonization, fungal ball and allergic fungal rhinosinusitis) and invasive disease (acute invasive rhinosinusitis, chronic invasive rhinosinusitis and granulomatous invasive rhinosinusitis). A diagnosis of fungal rhinosinusitis is established by combining findings on history, clinical examination, laboratory testing, imaging and histopathology. The immunocompetence of the patient is of great importance, as invasive fungal rhinosinusitis is uncommon in immunocompetent patients. With the exception of localized fungal colonization, treatment of all forms of fungal rhinosinusitis relies heavily on surgery. Systemic antifungal agents are a fundamental component in the treatment of invasive forms, but are not indicated for the treatment of the non-invasive forms. Antifungal drugs may have a role as adjuvant therapy in allergic fungal rhinosinusitis, but evidence is poor to support recommendations. Randomized controlled trials need to be performed to confirm the benefit of immunotherapy in the treatment of allergic fungal rhinosinusitis. In this article, we will summarize the current literature, addressing the controversies regarding the diagnosis and management of fungal rhinosinusitis, and focussing on those aspects which are important for clinical immunologists and allergists.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is caused by an exaggerated T(H)2 response to the ubiquitous mold Aspergillus fumigatus. ABPA develops in a small fraction of patients with cystic fibrosis and asthma, suggesting that intrinsic host defects play a major role in disease susceptibility. This article reviews current understanding of the immunopathology, clinical and laboratory findings, and diagnosis and management of ABPA. It highlights clinical and laboratory clues to differentiate ABPA from cystic fibrosis and asthma, which are challenging given clinical and serologic similarities. A practical diagnostic algorithm and management scheme to aid in the treatment of these patients is outlined.

The epidemiology and prevention of invasive aspergillosis

Over the past two decades, the incidence of invasive aspergillosis (IA) has risen inexorably. This is almost certainly the consequence of the more widespread use of aggressive cancer chemotherapy regimens, the expansion of organ transplant programmes and the advent of the acquired immunodeficiency syndrome (AIDS) epidemic. Despite the development of new approaches to therapy, IA still remains a life-threatening infection in immunocompromised patients and is the most important cause of fungal death in cancer patients. It is clear that the prevention of severe fungal infection by the use of effective infection control measure should be the priority of the teams involved in managing at-risk patients. The evidence from clinical and molecular epidemiological studies is reviewed and current thinking on sources and routes of transmission of the organism are discussed. Our increasing understanding of these has led to the development of a variety of environmental and general strategies for the prevention of IA. It is anticipated that these, coupled with the use of prophylactic antifungal agents active against Aspergillus spp., will have a significant impact upon the morbidity and mortality associated with this infection.

Aspergillus fumigatus peptides differentially express Th1 and Th2 cytokines

Relevant allergens from Aspergillus fumigatus associated with allergic bronchopulmonary aspergillosis (ABPA) have been cloned and expressed. The pathogenesis of ABPA probably depends on specific cytokines and immunoglobulins secreted by lymphocytes on stimulation with different epitopes of those allergens. In the present study, we synthesized peptides of 12-16 amino acids from the sequence of Asp fI and compared their immunological responses in four mice strains (BALB/c, C57BL/6, AKR, and CBA). Of the five peptides studied for their cytokine profile, one showed a clear Th1, whereas another showed a Th2 response. The remaining three peptides varied in their immunoreactivity. The results suggest that a number of epitopes of diverse activities are present in individual molecules and may be involved in the pathogenesis of ABPA through differential cytokine secretions.

Immunodiagnosis of aspergillosis

Aspergillus species are ubiquitous fungi and have been implicated as the causative agents of a variety of lung disorders in humans. These disorders include allergic, saprophytic, and systemic manifestations. The allergic disorders mainly affect atopic persons, and invasive or systemic diseases affect immunosuppressed individuals. Immunodiagnosis can help the practitioner diagnose these diseases. Demonstration of circulating antibodies is a useful criterion, but the lack of dependable and standardized antigens is a limiting factor in the diagnosis of most Aspergillus-induced diseases. Despite this limitation, however, immunodiffusion and enzyme-linked immunosorbent assays have been widely used for the detection of antibodies in the sera of patients with aspergillosis. Similarly, crude and semipurified antigens are being used to demonstrate skin hypersensitivity in patients, and several methods have been useful in the detection of antigenemia in patients with invasive aspergillosis. With a growing number of reports on the incidence of aspergillosis and an increase in the number of immunosuppressed individuals in the population, more rapid methods and more reliable reagents for immunodiagnosis are needed. With recent attempts at obtaining reliable reagents for through hybridoma technology and molecular biological techniques, substantial progress toward efficient immunodiagnosis may be achieved.

A pathologic study of allergic bronchopulmonary aspergillosis

A lung biopsy specimen was obtained from a 10-year-old boy with cystic fibrosis and allergic bronchopulmonary aspergillosis. Light microscopy revealed a marked inflammatory process that was largely bronchocentric. Infiltrating cells included lymphocytes, plasma cells, monocytes, and numerous eosinophils. Elastin layers were intact in blood vessels and markedly disrupted in bronchioles. By immunofluorescent, major basic protein was demonstrated in eosinophils, was freely deposited outside of eosinophils, especially in the interlobular septum, and was taken up by macrophages. A number of lymphocytes stained positively for IgE. Through an immunoperoxidase stain, septate hyphae of Aspergillus were clearly observed in the lung parenchyma. A significant increase in interleukin-2 positive-staining T cells was observed with an approximate 2:1 ratio of helper to suppressor cells. The use of newer immunohistologic techniques has enabled us to gain additional insights into the pathogenesis of allergic bronchopulmonary aspergillosis.

Pathogenetic and serological aspects of pulmonary aspergillosis

Af is an important pathogen of the bronchopulmonary system, and the clinical spectrum encompasses aspergilloma, CNPA, IPA, ABPA, bronchial asthma, and allergic alveolitis. Bronchial carriage may, however, not always be associated with pathological effects. The polymorphism of the aspergillus-related disorders seems mostly to depend upon the different responses of the hosts. This review considers the antigenic composition of Af and specific antibody responses in man in relation to the pathogenesis and diagnosis of the various forms of pulmonary aspergillosis. More than 200 macromolecular components have been listed for Af and more than 30 antigens found to react with human sera. Serum antibodies to Af are common in healthy subjects. Schønheyder and his associates (A-L) have shown that IgG, IgA and IgM antibodies in healthy subjects are directed towards antigens to which also patients with aspergillosis strongly react. With immunofluorescent staining these antigens were found to be associated with hyphal walls, and a MW 470,000 fraction from ruptured mycelium was most reactive in ELISA. The respiratory tract appears to be the major route for exposure since the humoral responses include IgA class antibodies, and sIgA antibodies are found in bronchial secretions. Moreover, IgG antibody levels to the MW 470,000 fraction correlate with occupational exposure and smoking habits. In patients with cystic fibrosis high IgG antibody levels to MW 470,000 and MW 25,000-50,000 antigen fractions were associated with the carriage of Af in the sputum. An individual patient's level of IgA antibodies to the MW 470,000 fraction was inversely related to the Af carrier rate, and this was also true for IgE dependent reactivity to Af antigens. These observations indicate that IgG antibodies to some antigens mirror the extent of antigenic exposure, whereas some IgA and IgE antibodies may play a protective role against bronchial colonization with Af. IgG antibody determinations by ELISA were found to provide a higher diagnostic efficacy in pulmonary aspergillosis than IgA antibody assays. With IgG antibodies there were statistically significant differences between patients and the controls and there was little overlap of ELISA values between the groups. The fractions of MW 250,000 with catalase activity and MW 25,000-50,000 with protease activity, were most suitable for serological diagnosis. A gel immunoelectrophoretic assay proved Af catalase to be a major diagnostic antigen in patients with aspergilloma or with an apical aspergillus lung infiltrate.(ABSTRACT TRUNCATED AT 400 WORDS)

Diagnosis of allergy: in vitro testing

Relatively few laboratory tests are of proven value in the differential diagnosis and management of allergic diseases. Immunoassays for IgE and for IgE antibodies are the mainstays. Measurement of IgE in serum is advocated as a first-order laboratory test in the differential diagnosis of allergic disease in children and adults. The usefulness of laboratory tests for IgE antibodies in serum, once a subject of debate in the clinical allergy literature, is now firmly established. Confusion, in respect to the use of these tests, is most evident in clinical situations which have been the subject of limited clinical investigation, e.g., the use of tests for IgE antibodies to screen for allergic disease, the indications for their use in patients treated with allergen immunotherapy, and the diagnostic specificity of IgE antibodies to foods as an indicator of food-induced allergic symptoms. Confusion is also apparent in the interpretation of borderline test results, i.e., results which may indicate the presence of low titers of IgE antibodies, and in defining the optimum format for reporting results to maximize the analytical sensitivity of the test method. This review addresses the ambiguities noted above in the interpretation of results. The paragraphs that follow also consider the possible uses of laboratory tests for inflammatory mediators of immediate hypersensitivity, for IgG antibodies to allergens, and of tests designed to evaluate the in vitro functions of lymphocytes in patients with allergic disease.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) occurs as a complication of asthma. It presents as an infiltrative pulmonary disorder with respiratory and systemic symptoms, eosinophilia, elevated total serum IgE, and skin sensitizing, as well as precipitating antibodies to Aspergillus fumigatus. Sputum cultures are not always positive for the organism. If unchecked, the disease may lead to bronchiectasis and ultimately pulmonary fibrosis. Therapy consists mainly of corticosteroids.

Allergic bronchopulmonary candidiasis

A patient had an illness consistent with allergic bronchopulmonary candidiasis. She had asthma, fleeting pulmonary infiltrate, immediate skin reactivity and precipitating antibody against Candida albicans, elevated total serum IgE concentration, elevated IgE and IgG antibody activity against C albicans, and two positive sputum cultures for C albicans. Serial serologic studies showed a significant decrease of serum IgE levels and IgE antibody activity after corticosteroid treatment.

Environmental aerobiological studies in allergic bronchopulmonary aspergillosis

An aerobiological pilot study was undertaken to measure airborne concentrations of Aspergillus spores in and around the dwellings of two patients with allergic bronchopulmonary aspergillosis (ABPA). The aim of the investigation was 1) to find a specific source of Aspergillus antigen, and 2) to find out whether disease activity, or exacerbation, paralleled Aspergillus spore prevalence. In the environment of the first patient heavy spore contaminated air was found in a cow-shed, and the adjacent hayloft and scullery. The patient experienced no typical exacerbation during the study period, probably because she now scrupulously avoided this source. The environment of the second patient contained lower spore concentrations in and around the house, and the patient had no typical exacerbation, possibly due to low-intensity exposure. Both patients, however, had increased bronchial obstruction during periods with high Aspergillus spore content in the outside air. The results suggest that avoidance of Aspergillus spore sources and low overall exposure may play a major role in preventing exacerbation of the disease.

Antigen and antibody attachment in ELISA for Aspergillus fumigatus IgG antibodies

Four commercial antigen extracts of Aspergillus fumigatus were evaluated for use in a rapid enzyme-linked immunosorbent assay (ELISA) for anti-A. fumigatus IgG. Initial binding of both somatic and culture filtrate preparations to a polyvinyl chloride solid phase was concentration dependent and increased with incubation time. Antigen binding to the solid phase was reproducible. Binding of A. fumigatus precipitin-positive serum to bound antigen was rapid. All four A. fumigatus antigens demonstrated similar dose-response curves when tested against pooled sera containing a high titre of A. fumigatus antibodies. Detectable activity in precipitin test-negative sera decreased rapidly with dilution. All the antigen preparations were found to be suitable for ELISA procedures and permit the rapid determination of IgG antibodies to A. fumigatus.

IgG receptors on the mast cells

Antisera to the IgG subclasses, 1, 2a, 2b, and 2c, induced histamine release from mast cells obtained from the peritoneal washings of Lister hooded rats. The maximum responses obtained with anti-IgG1 and anti-IgG2a were as great as that for anti-IgE (more than 60% histamine release). Cells from unresponsive Wistar rats which did not secrete appreciable amounts of histamine in response to any of the antisera, produced on active sensitization with ovalbumin a small but significant response on challenge with anti-IgG1 and anti-IgG2b as well as with anti-IgE. Passive sensitization with rat myeloma serum of mast cells from the unresponsive rats produced a large response on challenge with anti-IgE but no release to the anti-IgG group 2 subclasses. IgE myeloma serum (1:1000) neutralized the histamine-releasing activity on anti-IgE serum (87% inhibition) and the antisera to all subclasses of IgG. When the IgE in the myeloma serum was inactivated by heating, the response to the IgG antisera remained completely inhibited except for anti-IgG2a where some reversal was observed. When purified myeloma IgE (30 microgram/ml) was used in place of whole serum, marked inhibition (86%) of the response to anti-IgE was obtained leaving the responses to the IgE subclasses unaffected (except for IgG2a, which was 65% inhibited).

Positive immediate skin tests in cystic fibrosis: a possible role for Pseudomonas infection

A review was made of the medical records of 49 patients from whose sputum mucoid Pseudomonas aeruginosa had been isolated over a 20-month period. This showed that 31 of 42 had positive immediate skin prick tests to common antigens. 21 had positive reactions to Aspergillus fumigatus antigens and 23 had precipitins to A. fumigatus antigen. 36 patients had had frequent courses of antibiotics and airway obstruction was present in 47. These results have prompted the hypothesis that the positive skin test reactions in patients with cystic fibrosis may in part be explained by the abundance of fungal and bacterial antigens that occur in the respiratory tract of these patients. The former antigens sensitize the immunoglobulin E producing cells whilst the latter exert an adjuvant action and facilitate this.

A guide to the recent literature on aspergillosis as caused by Aspergillus fumigatus, a fungus frequently found in self-heating organic matter

Spores of Aspergillus fumigatus have been found to be abundantly present in the outdoor air at a site where large scale experimental composting of sewage sludge is in progress at Beltsville, Maryland. The health significance of this finding, for that site and for others in the future, is still only incompletely understood. Further studies are in progress to characterize absolute concentrations of the spores of the fungus in air at the site, spore dispersal by air from composting operations, and background environmental spore levels in air. The present paper contains a list of references to papers on health effects of A. fumigatus, many published in the past ten years, along with a review of the same designed to assist the reader in finding information on particular aspects of the subject in the literature. It is intended primarily as an aid to individuals interested in sludge composting and wishing to attain an insight into the A. fumigatus-composting situation, but it may also interest others concerned with other substrates which become moldy at 40--50 C. A. fumigatus has been found in great numbers in naturally and artificially heated environments such as decaying leaves, compost heaps, solar heated sloughs, cooling canals for nuclear power generators, silos, grain storage bins, boiler rooms, detritus around steam turbines and sauna baths. The evident practical merits of sludge composting have been described elsewhere; the information presented here has its main significance in respect to requirements for choice of locations for composting sites and to process and design criteria.

Incidence of immediate sensitivity to Aspergillus fumigatus in a North American asthmatic population

Allergic bronchopulmonary aspergillosis might be less frequent in North America because the incidence of immediate sensitivity by asthmatics to A. fumigatus is less. In order to check this hypothesis, 200 asthmatics were skin tested with two extracts of A. fumigatus which had been shown to produce positive reactions in fifty patients who had allergic aspergillosis. Of the asthmatics, 21.5% reacted to the commercial extract by prick testing and 39% by intradermal testing. Using an extract kindly provided by Professor Pepys, 19.5% reacted to a concentration of 1 mg/ml and 31.5% to 10 mg/ml. By the prick method, 21.5% reacted to both extracts. Specific IgE was measured with one of the extracts and a good correlation (r = 0.48) was found with the size of the prick reaction. The increase in specific IgE was reflected in the increase of total IgE (r = 0.84). The authors conclude that the incidence of immediate sensitivity to A. fumigatus in asthmatic patients in North America is at least equal to that found in the U.K.

Allergic bronchopulmonary aspergillosis in pediatric practice

Twelve cases of allergic bronchopulmonary aspergillosis in the pediatric age group are reported. The average age of diagnosis was 14.5 years with a range from 6 to 18 years. All patients had a history of pulmonary infiltrations or atelectasis or both documented by chest radiographs. Eight patients had bronchograms or tomograms, and seven of them showed proximal bronchiectasis. Total serum IgE concentrations were elevated in all patients. Preciptitating antibodies against Aspergillus fumigatus were positive in all patients at the time of diagnosis, and became negative in some after therapy. The specific IgE or IgG antibody activity agaist Af was elevated in all 12 patients. After prednisone was started the total serum IgE sharply declined to a plateau and remained at this level until a flare of allergic aspergillosis occurred. A flare of allergic aspergillosis is characterized by an increasing total serum IgE concentration followed by pulmonary infiltration. Clinical and roentgenologic improvements were observed after steroid therapy. The importance and methods of early diagnosis in the pediatric population are discussed.

Allergic bronchopulmonary aspergillosis (ABPA): studies on the general and specific humoral response

Serum specimens from 138 patients suffering from chronic respiratory disorders including 63 with allergic bronchopulmonary aspergillosis (ABPA), 2o with suspected ABPA, 15 with pulmonary tuberculosis, 14 with bronchial asthma, 10 with chronic bronchitis and 6 with miscellaneous pulmonary conditions were studied for circulating antibodies to Aspergillus. The ammonium sulfate test was empolyed with an iodine-125 labeled mycelial component derived from Aspergillus fumigatus. When compared to normal controls from the same area, this test indicated that sera from 82 per cent of patients with ABPA had elevated binding titers to the radiolabeled antigenic component. Immunodiffusion using a culture filtrate antigen from A. fumigatus, revealed precipitating antibody to this fungus in 89 percent of sera from ABP patients. The majority of patients with ABPA demonstrated marked elevations of total serum IgE, moderate elevations of serum IgA and IgD and slightly increased levels of IgG and IgM.

Immunologic responses to therapy in allergic bronchopulmonary aspergillosis: serum IgE value as an indicator and predictor of disease activity

Two patients, a child and an adult, with allergic bronchopulmonary aspergillosis were studied over an 18-month period. Initially elevated total serum IgE levels fell during prednisone therapy and rose prior to and during an exacerbation. Total serum IgG fell with therapy, whereas the values of IgA and IgM remained constant. Specific IgG and IgE values against Aspergillus fumigatus as measured by radioimmunoassay were elevated in both patients. Specific IgE values increased in each patient prior to exacerbation, whereas specific IgG values increased in only one patient at the time of exacerbation. Immunologic evaluation may provide an assessment of disease activity of prospective value.

Evidence that Aspergillus fumigatus growing in the airway of man can be a potent stimulus of specific and nonspecific IgE formation

Serum IgE levels in patients with allergic bronchopulmonary aspergillosis are elevated but the degree of elevation varies markedly. Serum IgE levels in patients with aspergillomas may be strikingly elevated or normal. Absorption of serums with antigens of Aspergillus fumigatus combined with a solid phase radioimmunoassay technic demonstrated that both immunoglobulin E (IgE) and immunoglobulin G (IgG) antibody activity against A. fumigatus were markedly reduced without a parallel reduction in serum total IgE. These results indicate that the very high levels of serum IgE found in allergic bronchopulmonary aspergillosis and aspergilloma are not all specific IgE. These results are similar to those observed in rats infested with Nippostrongylus brasiliensis. An explanation for the elevations of IgE levels in infestations with A. fumigatus may be analogous to the postulate that parasite-produced materials may result in T cell stimulatory factors for IgE-producing cells. Alternatively, A. fumigatus organisms may produce materials that inhibit T suppressor lymphocytes.

Studies in chronic allergic bronchopulmonary aspergillosis. 3. Immunological findings

Precipitin tests by two different methods, double-diffusion (DD) and counterimmunoelectrophoresis (CIE), and measurements of total and specific IgE against Aspergillus fumigatus were made in 50 patients with chronic allergic bronchopulmonary aspergillosis and in three control groups--atopics with a positive immediate prick test to A. fumigatus but no evidence of allergic aspergillosis, atopics with a negative prick test to A. fumigatus, and non-atopics. Precipitins were found in 84% and 78% of the patients with aspergillosis by the DD and CIE methods respectively. Precipitins were also found in 6 out of 27 (22%) patients with a positive prick test to A. fumigatus but no evidence of aspergillosis and in 1 of 24 patients with a negative prick test to A. fumigatus. The means of specific and total IgE values were significantly higher in the group of patients with aspergillosis than in the three other groups of patients. The increase in specific but not total IgE showed a statistically significant correlation with positive precipitin tests in the patients with aspergillosis. Total IgE but not specific IgE values were significantly higher (0-02 less than P less than 0-05) in patients who had had a transient radiographic shadow in the previous three months. Positive precipitin tests were also significantly correlated with the number of transient shadows in the past and with the interval of time since the last transient shadow.

Treatment of allergic aspergillosis with triamcinolone acetonide aerosol

The successful management of a patient with allergic asperillosis with triamcinolone acetonide for one year is reported. This patient had been maintained previously on systemic attempt to withdraw systemic corticosteroids continuously for eight years. An initial attempt to withdraw systemic steroids after initiation of aerosol therapy was unsuccessful; however, following bronchoscopic removal of mucus plugs, the transfer to maintenance therapy with triamcinolone aerosol alone was uneventful.

Analysis of cellular and protein content of broncho-alveolar lavage fluid from patients with idiopathic pulmonary fibrosis and chronic hypersensitivity pneumonitis

To evaluate cellular and protein components in the lower respiratory tract of patients with idiopathic pulmonary fibrosis (IPF) and chronic hypersensitivity pneumonitis (CHP), limited broncho-alveolar lavage was done in 58 patients (19 IPF, 7 CHP, and 32 controls). Analysis of the cells and protein in the lavage fluids from patients with IPF revealed an inflammatory and eosinophilic response and a significant elevation of IgG in the lungs. With corticosteroid therapy, inflammation diminished but eosinophils remained. Lavage fluid from patients with CHP also had eosinophils and elevated levels of IgG. However, in contrast to IPF, lavage fluid from CHP patients contained IgM, fewer inflammatory cells, and a strikingly increased number (38-74%) of lymphocytes. Identification of lavage lymphocytes in CHP showed that T lymphocytes were significantly elevated and B lymphocytes were decreased compared to peripheral blood. These studies suggest nthat the lung in IPF and CHP may function as a relatively independent immune organ, and that analysis of cells and proteins in broncho-alveolar lavage fluid may be of diagnostic, therapeutic, and investigative value in evaluating patients with fibrotic lung disease.

Monoclonal IgE with renal failure

Only four cases of immunoglobulin E (IgE) monoclonal "gammapathies" have been reported previously. Discussed here is a 57 year old man who presented with hypertension and the nephrotic syndrome. A monoclonal IgE-kappa component (0.6 mg/ml), which did not appear as an M spike on protein electrophoresis, was demonstrated by immunoelectrophoresis in the serum and urine. The patient's condition deteriorated rapidly due to renal failure, and he died five weeks after the diagnosis was made. Pathologic examination disclosed extensive glomerular lesions, but amyloid was not detected by light or electron microscopy. The possible relationship between the monoclonal gammapathy and kidney impairment is discussed.

Extrinsic allergic alveolitis after Aspergillus fumigatus inhalation. Evidence of a type IV immunologic pathogenesis

Three weeks after a massive inhalation of mold present on infected oats, a farmer's wife had extrinsic allergic alveolitis. Aspergillus fumigatus was cultured from the moldy oats and from deep bronchial washings obtained at fiberoptic bronchoscopy. Spores and hyphae characteristic of Aspergillus species were demonstrated within granulomas in the pulmonary tissue obtained by transbrochial biopsy. Serum precipitins, delayed (48 hour) cutaneous hypersensitivity and in vitro lymphocyte transformation to A. fumigatus were demonstrated. The findings in this case suggest that a type IV immunologic response and subsequent (lymphocyte-mediated) tissue inflammation may underlie the pathogenesis of this and other forms of hypersensitivity pneumonitis.

Raised serum immunoglobulin E in Wegener's granulomatosis

Five patients with Wegner's granulomatosis were found to have significantly raised serum immunoglobulin E (IgE) levels. The rise in IgE was not related to the extent of clinical involvement, was not part of a generalized serum immunoglobulin rise, and was not associated with eosinophilia. Raised serum IgE may be a clue to the pathogenesis of this disease.

Quantitative levels of immunoglobulin E in advanced tuberculosis

Quantitative levels of immunoglobulin E (IgE) were determined in samples of sera obtained from 29 patients with proven moderate to far-advanced tuberculosis. The sensitive radioimmunoassay test for IgE was used. Statistical analysis of the results revealed no difference in IgE values as compared to a control group of normal sera. In contrast to other chronic pulmonary infections, such as bronchopulmonary aspergillosis, the IgE level in pulmonary tuberculous infection is of no diagnostic significance. Simultaneous determination of levels of immunoglobulins G, A, M, and D (IgG, IgA, IgM, IgD) in these same sera by radial immunodiffusion showed elevated IgG and lowered IgM levels in the tuberculous patients, confirming previous studies. The significance of these alterations in immunoglobulin levels is unclear and may represent a secondary phenomenon rather than a primary host response.

Hyperimmunoglobulinemia E in a child with allergic bronchopulmonary aspergillosis and bronchiectasis

A 12-year-old boy was hospitalized for resection of a bronchiectatic lesion. Investigation of an elevated cencentration of serum IgE led to a diagnosis of allergic bronchopulmonary aspergillosis. ABPA has rarely been described in the pediatric age group. This hypersensitivity lung disease is characterized by intermittent wheezing, fever, recurrent pulmonary infiltrates, eosinophilia, hyperimmunoglobulinemia E, and Type I (allergic) skin reactivity to aspergillus extract. Hyphae of aspergillus may also be found in expectorated brown mucus plugs. Type III (Arthus) skin test response and presence of precipitating antibody to this fungus may be demonstrated. Central bronchiectasis or pulmonary fibrosis may result from uncontrolled progression of this disease.

Lymphocyte sensitization to Aspergillus fumigatus antigens in pulmonary diseases in man

In vitro studies of T-lymphocyte responses using five different batches of Aspergillus fumigatus antigens, were undertaken in twelve patients with A. fumigatus related lung disease and in three normal controls. Using a leucocyte migration method, five of the twelve patients showed significant inhibition of leucocyte migration with a migration index of 0-80 or less to A. fumigatus, but in only three was this demonstrated with more than one batch of antigen (one patient with aspergilloma and two with bronchopulmonary aspergillosis). The same antigens were used in lymphocyte transformation tests. Only two patients, one with aspergilloma and one with bronchopulmonary aspergillosis, showed clearly significant transformation although there were several borderline results. Only three patients had evidence of delayed skin responses to A. fumigatus antigens in vivo, one with aspergilloma, one with bronchopulmonary aspergillosis and one with atypical bronchopulmonary aspergillosis. Two of these three patients also had one or more positive in vitro test results. Thus T-lymphocyte sensitization to A. fumigatus as demonstrated by these in vitro methods, although present in occasional patients, was not clearly related to any one particular clinical syndrome in this small group of patients with aspergillus related pulmonary disease. There was, however, one of the three aspergilloma patients with positive lymphocyte transformation to all five batches of antigens and having higher transformation indices than in any other patient. This suggest that lymphocyte studies should be extended in this group. In contrast to the frequent negative results using A. fumigatus antigens, evidence of T-lymphocyte sensitization to either Candida albicans or Mycobacterium tuberculosis or both, was shown by positive delayed hypersensitivity skin responses and in vitro inhibition of leucocyte migration in the majority of the patients, despite which lymphocyte transformation was often negative. The possibility of impaired capacity to transform is supported by the finding of an impaired response to phytohaemagglutinin (PHA) in four of the twelve cases. This information, together with other data discussed, helps to complete the contrasting immunological profiles seen in different Aspergillus fumigatus related lung diseases.