Late sequelae of allergic bronchopulmonary aspergillosis

Use of Intravenous Pulse Steroids to Treat Allergic Bronchopulmonary Aspergillosis in a Non-Compliant Asthmatic Adolescent

Allergic bronchopulmonary aspergillosis (ABPA) is an immune-mediated inflammatory airway disease that predominantly affects patients with cystic fibrosis (CF) and, less commonly, patients with asthma. ABPA can lead to irreversible lung injury and bronchiectasis if not treated early and aggressively. Long-term oral steroids are the standard therapy of ABPA. However, it is associated with an increased risk of steroids side effects and possible medication noncompliance. Monthly intravenous pulse methylprednisolone (IV-PS) has been used as an alternative to oral steroids to treat CF-related ABPA with a reportedly similar clinical response and less steroid-related side effects. To our knowledge, the use of IV-PS in asthma-related ABPA has not been previously reported. We report the successful management of asthma-related ABPA in an adolescent using intravenous pulse methylprednisolone in addition to oral itraconazole with no significant steroid-related side effects.

Prevalence of Aspergillus hypersensitivity and allergic bronchopulmonary aspergillosis in patients with bronchial asthma at a tertiary care center in North India

Background:

The prevalence of Aspergillus hypersensitivity (AH) and allergic bronchopulmonary aspergillosis (ABPA) has been variably reported. Systematic data regarding Aspergillus sensitization and ABPA are lacking from this part of the country.

Objectives:

The aim of this study was to evaluate the prevalence of AH and ABPA in Uttar Pradesh.

Setting and Design:

This was prospective observational study. All patients attending outpatient Department of Pulmonary Medicine of our institute were included in the study.

Subjects and Methods:

Consecutive asthmatic patients underwent screening for ABPA using Aspergillus skin test (AST). Those showing a positive response to AST were further evaluated for ABPA.

Results:

During the study, 350 patients (192 males, 158 females, mean ± standard deviation age: 38.3 ± 12.8) were screened with AST. One hundred and twenty-three patients (35.1%) were tested positive for AST and 21.7% of patients were diagnosed as ABPA.

Conclusions:

A high prevalence rate of ABPA was observed at our chest clinic. Although comparable with published data from other tertiary centers, it does not represent the true prevalence rates in asthmatics because of high chances of referral bias.

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.

Allergic bronchopulmonary aspergillosis: a clinico-serological correlation with radiologic profile

OBJECTIVE

To study the different types of radiological presentations of ABPA in a tertiary clinic in Northern India and analyze them with respect to serological profile and clinical characteristics.

METHODS

We performed a retrospective analysis of clinical, serological and radiological characteristics of ABPA patients registered at a unit of tertiary pulmonary care center in North India. The patients were classified based on radiological presentation into ABPA-S, ABPA-CB and ABPA-CB-ORF and the differences in these groups were studied.

RESULTS

There were 112 patients with ABPA between age 6 and 75 years. About 8.9% (n = 10) of patients had a history of smoking and 38.4% (n = 43) had a history of prior anti-tuberculosis treatment. The median duration of symptoms was longest in the ABPA-CB-ORF group (15 years) followed by ABPA-CB (7 years) and ABPA-S (5 years). Mean serum total IgE level in the ABPA-CB-ORF group was 14 330 IU/mL followed by the APBA-CB (3700 IU/mL) and ABPA-S (1020 IU/mL) groups (p < 0.0001). The ABPA-CB-ORF group had the highest median specific anti-Aspergillus fumigatus IgE followed by ABPA-CB and ABPA-S groups (42.24 kU/L, 20.65 kU/L and 3.44 kU/L, respectively) (p < 0.0001). ABPA-CB-ORF group had the highest percentage of positive serum precipitins against Aspergillus spp. (92%) followed by ABPA-CB (79.6%) and ABPA-S (68%) (p < 0.05).

CONCLUSIONS

The patients with more pronounced lung damage in the form of ABPA-CB and ABPA-CB-ORF had higher serological parameters suggestive of increased systemic inflammation. Hence, ABPA may be categorized as mild (ABPA-S), moderate (ABPA-CB) and severe (ABPA-CB-ORF) categories which oscillate between remission and exacerbation phases.

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.

Managing cystic fibrosis: strategies that increase life expectancy and improve quality of life

The survival of patients with cystic fibrosis (CF) continues to improve. The discovery and cloning of the CFTR gene more than 21 years ago led to the identification of the structure and function of the CFTR chloride channel. New therapies based on the understanding of the function of CFTR are currently under development. The better clinical status and improved survival of patients with CF is not only a result of understanding of the molecular mechanisms of CF but also a result of the development of therapeutic strategies that are based on insights into the natural course of the disease. Current CF treatments that target respiratory infections, inflammation, mucociliary clearance, and nutritional status are associated with improved pulmonary function and reduced exacerbations. Patients benefit from treatment at a specialized CF center by a multidisciplinary dedicated team with emphasis being placed on frequent visits, periodic testing, and monitoring adherence to therapy. The purpose of this review is to survey recent developments in CF care that are responsible for the improved survival and quality of life of patients with CF.

Intravenous monthly pulse methylprednisolone treatment for ABPA in patients with cystic fibrosis

BACKGROUND

Allergic bronchopulmonary aspergillosis (ABPA) in patients with CF is associated with frequent exacerbations and deterioration of lung function. Oral corticosteroids are standard therapy for ABPA and are associated with severe side effects. Monthly pulses of high-dose intravenous methylprednisolone (HDIVPM) are an effective therapy for autoimmune diseases with fewer side effects compared to oral prednisone, implicating its use for patients with CF who suffer from ABPA.

METHODS

9 patients with CF and ABPA (4 male, 5 female, ages 7-36 years) received HDIVPM (10-15 mg/kg/d), for 3 days per month, and itraconazole, until clinical and laboratory resolution of ABPA.

RESULTS

All patients showed clinical and laboratory improvement (FEV(1) increase, serum IgE levels and total eosinophil counts decrease) and treatment was discontinued after 6-10 pulses. Adverse effects were minor and disappeared shortly after each IV pulse therapy.

CONCLUSION

High-dose IV-pulse methylprednisolone is an effective treatment for ABPA in CF with minor side effects.

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.

Clinical significance of hyperattenuating mucoid impaction in allergic bronchopulmonary aspergillosis: an analysis of 155 patients

BACKGROUND

Allergic bronchopulmonary aspergillosis (ABPA) is a disease that presents with diverse clinicoradiologic manifestations. High-attenuation mucus (HAM) is a characteristic radiologic finding seen in patients with ABPA; however, the clinical significance of the entity remains unknown.

AIMS AND OBJECTIVES

To describe the outcome of patients with ABPA who were demonstrated to have HAM, and compare with the outcome of patients without HAM.

METHODS

All consecutive patients with asthma presenting to the Chest Clinic of this institute over a 4-year period were screened with an Aspergillus skin test. Patients with positive findings were further investigated, and the diagnosis of ABPA was confirmed based on predefined criteria. The patients were further classified into two groups based on the presence of HAM on HRCT scan.

RESULTS

During the study period, 755 patients were screened for ABPA using the Aspergillus skin test; 291 patients (38.5%) had positive findings, and ABPA was diagnosed in 155 patients (mean age, 33.98 years; 76 women). Twenty-nine patients (18.7%) with ABPA were identified to have HAM on HRCT scans at presentation. The baseline characteristics were similar between the two groups, but patients with HAM had higher mean eosinophil counts, higher mean serum total IgE, and higher Aspergillus fumigatus-specific IgE levels. On multivariate analysis, both the severity of bronchiectasis and HAM predicted relapse of ABPA (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13 to 1.42; and OR, 3.61; 95% CI, 1.23 to 10.61, respectively). Failure to achieve complete remission was influenced by the severity of bronchiectasis but not by HAM (OR, 1.55; 95% CI, 1.29 to 1.85; and OR, 3.41; 95% CI, 0.89 to 13.1, respectively).

CONCLUSIONS

HAM impaction in ABPA is associated with initial serologic severity and frequent relapses but does not seem to influence complete remission.

Allergic Bronchopulmonary Aspergillosis

AIMS AND OBJECTIVES

To describe the experience of screening patients with asthma for allergic bronchopulmonary aspergillosis (ABPA) presenting to a chest clinic. The clinical, serologic, radiologic, and treatment aspects including outcome of ABPA are also described.

METHODS

All consecutive patients with asthma presenting to the chest clinic over a period of 2 years were screened with an Aspergillus skin test. Patients who were found to be positive were further investigated for ABPA. Patients were also arbitrarily classified as ABPA-seropositive (ABPA-S), ABPA with central bronchiectasis (ABPA-CB), and ABPA-CB with other radiologic findings (ABPA-CB-ORF) based on the high-resolution CT findings.

RESULTS

Five hundred sixty-four patients were screened using an Aspergillus skin test; 223 patients (39.5%) were found to be positive, and ABPA was diagnosed in 126 patients (27.2%). There were 34 patients (27%) with ABPA-S, 42 patients with ABPA-CB, and 50 patients with ABPA-CB-ORF. Fifty-nine patients (46.8%) had received antitubercular therapy in the past. The vast majority of patients had bronchiectasis at presentation to our hospital. High-attenuation mucous impaction was noted in 21 patients (16.7%). There was no significant difference between the stages of ABPA and the duration of illness, the severity of asthma, and the serologic findings (ie, absolute eosinophil count, IgE levels [total] and IgE levels [for Aspergillus fumigatus]). The median duration of follow-up was 13 months (range, 9 to 38 months). All patients went into "remission" at 6 weeks. Twenty-five patients had a "relapse" during the course of their treatment. One hundred nine patients had "complete remission," 17 patients were classified as having "glucocorticoid-dependent ABPA," and 7 patients were classified as having "end-stage ABPA."

CONCLUSIONS

There is a high prevalence of ABPA in asthmatic patients presenting at our hospital. The disease entity is still underrecognized in India; the vast majority of patients have bronchiectasis at presentation, and almost half are initially misdiagnosed as having pulmonary tuberculosis. There is a need to redefine the definitions of ABPA and the optimal dose/duration of glucocorticoid therapy. This study reinforces the need for the routine screening of asthmatic patients with an Aspergillus skin test.

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.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) occurs in nonimmunocompromised patients and belongs to the hypersensitivity disorders induced by Aspergillus. Genetic factors and activation of bronchial epithelial cells in asthma or cystic fibrosis are responsible for the development of a CD(4)+Th2 lymphocyte activation and IgE, IgG and IgA-AF antibodies production. The diagnosis of ABPA is based on the presence of a combination of clinical, biological and radiological criteria. The severity of the disease is related to corticosteroid-dependant asthma or/and diffuse bronchiectasis with fibrosis. The treatment is based on oral corticosteroids for 6-8 weeks at acute phase or exacerbation and itraconazole is now recommended and validated at a dose of 200 mg/day for a duration of 16 weeks.

Exhaled nitric oxide in cystic fibrosis patients with allergic bronchopulmonary aspergillosis

Exhaled nitric oxide (NO) is thought to be a marker of asthmatic inflammation. Levels in cystic fibrosis (CF) are generally low. This study aimed to measure exhaled NO in CF patients at high risk of developing ABPA and patients at low risk. We studied nine patients at high risk of developing ABPA and 36 at low risk. The two groups were similar in age and spirometry. All patients in the high-risk group were taking oral or inhaled glucocorticoids, compared to 56% in the low-risk group (P=0.02). The exhaled NO levels were lower in the high-risk group than in the low-risk group (2.0 vs. 3.6 ppb), mean difference (95% CI) 1.6 (-3.6 to 0.4) ppb, P=0.001. On subgroup analysis of patients on oral glucocorticoids, the exhaled NO levels were significantly lower in patients with a high risk of developing ABPA (n=7) than patients with a low risk (n=8) (P=0.011). The number of patients who were on inhaled, but not oral glucocorticoids was too small to analyse usefully. Exhaled NO levels were lower in CF patients with a high risk of developing ABPA and on glucocorticoids. This may be because oral glucocorticoids exert a greater effect on exhaled NO than inhaled glucocorticoids. Alternatively, inducible nitric oxide synthase may be down-regulated by Aspergillus toxin.

Computed tomographic scanning of the lung in patients with allergic bronchopulmonary aspergillosis and in asthmatic patients with a positive skin test to Aspergillus fumigatus

BACKGROUND

Allergic bronchopulmonary aspergillosis is a disease of asthmatic patients which may follow a protracted course and result in chronic lung damage such as central bronchiectasis. In asthma uncomplicated by allergic bronchopulmonary aspergillosis, in particular in asthmatic patients with immediate hypersensitivity type skin reactions to Aspergillus fumigatus, the incidence of bronchiectasis is uncertain.

METHODS

Computed tomographic (CT) scans were performed in 17 asthmatic patients of mean (SE) age 60.1 (2.5) years, FEV1 49.4 (5.8)% predicted with allergic bronchopulmonary aspergillosis (all with current or previous positive precipitins to A fumigatus) and in 11 asthmatic patients of mean (SE) age 49.5 (5.8) years, FEV1 75.5 (6.5)% predicted, skin test positive for A fumigatus, but without the clinical or serological features of allergic bronchopulmonary aspergillosis (non-allergic bronchopulmonary aspergillosis group).

RESULTS

Bronchial dilatation was more common in the group with allergic bronchopulmonary aspergillosis, affecting 14 patients compared with two in the non-allergic bronchopulmonary aspergillosis group. Evidence of bronchiectasis was found in 43 of a possible 102 lobes of patients with allergic bronchopulmonary aspergillosis, compared with three of a possible 66 in the non-allergic bronchopulmonary aspergillosis group. Bronchial wall thickening was common to both, affecting 16 and nine patients respectively. Pleural thickening on CT scanning was common in the group with allergic bronchopulmonary aspergillosis, being noted in 14 patients compared with only three in the non-allergic bronchopulmonary aspergillosis group.

CONCLUSIONS

Bronchiectasis is common in allergic bronchopulmonary aspergillosis but occurs only occasionally in asthmatic patients with a positive skin test to A fumigatus but without other features of the disease.

Cytology of allergic bronchopulmonary aspergillosis

The cytologic features of a case of allergic bronchopulmonary aspergillosis (ABPA) are reported and the literature reviewed. The bronchial brushing smears in this case showed mucus that contained laminated aggregates of eosinophils with scattered Charcot-Leyden crystals and fungal hyphae. These cytologic findings, overlooked by the initial examining pathologist, reflected the "mucoid impaction of bronchi" component of ABPA and are therefore diagnostic of ABPA. A cytologic diagnosis of a clinically unsuspected ABPA would lead to the correct treatment and prevent unnecessary surgery.

Period prevalence of allergic bronchopulmonary mycosis in a regional hospital outpatient population in Ireland 1985-88

The period of prevalence, 1988 inclusive, of Allergic Bronchopulmonary Aspergillosis (ABPA) and Allergic Bronchopulmonary Candiasis (ABPC), the two most frequently reported forms of allergic Bronchopulmonary Mycosis (ABPM), was investigated in an Irish regional hospital respiratory medicine outpatients, catchment area population 536,000. ABPM was defined by the presence of a majority of seven criteria: asthma, eosinophilia, elevated IgE, antibodies to Aspergillus Fumigatus or Candida Albicans, immediate skin test reaction to either fungus, culture of either fungus in sputum, and otherwise unexplained transient or permanent lung field x-ray abnormalities. New referrals were investigated for ABPM if they had asthma and eosinophilia, or asthma and lung field x-ray abnormalities. Fourteen patients with ABPM were identified from a total of 1390 new referrals, a period prevalence of just over one per cent. It is concluded that (1) ABPM is a relatively common disorder in an Irish regional hospital respiratory medicine outpatient population and (2) ABPC constitutes a higher proportion of this disorder than previously considered.

Immune responses to Aspergillus in cystic fibrosis

Aspergillus fumigatus (Af) is well recognized in its ability to colonize the respiratory tract in cystic fibrosis (CF). Furthermore, a number of the immune responses of the patient with CF to this organism have been characterized, and the immune inflammatory response to Af may result in allergic bronchopulmonary aspergillosis (ABPA). This study evaluated a series of immunologic parameters in 75 patients with CF in order to characterize more fully the spectrum of immune responses of those patients to Af and to clarify the relationship of those responses to the clinical features of ABPA. The patients could be classified into four groups, depending on the clinical and immunologic findings. Eight (10.7%) of the 75 patients had clinical and laboratory evidence of ABPA, including immediate cutaneous reactivity to Af, eosinophilia, elevated total serum IgE, elevated serum IgE-Af or IgG-Af, and precipitating antibody to Af. Ten (13.3%) patients had these features, except that the total serum IgE level was within the normal range. Forty (53.5%) of the patients had no significant criteria for ABPA but had varying immunologic responses to Af, such as immediate cutaneous reactivity to Af in 25 patients and elevated serum IgE-Af and/or IgG-Af in 19 patients. Seventeen (22.7%) patients had no evidence of an immunologic response, as determined by skin testing and serologic assays. The study demonstrated that the response of patients with CF to Af ranges from clinically apparent ABPA to a possible variant of ABPA, to a nondiagnostic group of features consistent with sensitization to Af or to no characteristic immune response.

Trial of ketoconazole in non-invasive pulmonary aspergillosis

A one year study of the efficacy of the antifungal agent ketoconazole in non-invasive pulmonary aspergillosis was carried out. Ten patients, seven with allergic bronchopulmonary aspergillosis and three with mycetoma, were studied. They were randomly allocated to receive 400 mg daily or placebo orally in a double blind fashion. In the treated group (n = 6), concentrations of serum IgG specific for Aspergillus fumigatus fell significantly during treatment (mean reduction 42% (SEM 2.2%) compared with determinations preceding the study). This effect was evident by three months and continued for the 12 months of treatment. Patients receiving placebo (n = 4) showed no significant change in serum IgG concentration (mean change + 10% (SEM 5.3%]. Asthmatic patients treated with ketoconazole (n = 4) had significantly lower symptom scores than those receiving placebo (n = 3) (+0.45%/month (SEM 6.9%) versus +27%/month (SEM 6.5%); p less than 0.001). None of the patients treated with ketoconazole reported any adverse effects. Ketoconazole may cause serious liver damage but its use may be justified in bronchopulmonary aspergillosis if further experience confirms its ability to alter the course of a potentially serious disease.

Aspergillosis--clinical aspects

Allergic bronchopulmonary aspergillosis (ABPA) is much more common than originally suspected, can have its onset in childhood and remain undiagnosed for years or decades, at which time it presents in a patient with end-stage fibrotic lung disease. In other patients, ABPA may cause a finite number of roentgenographic lesions and not be associated with chronic sputum production or widespread bronchiectasis. Clinical symptoms range from the patient being asymptomatic with a new roentgenographic infiltrate being suspected only by a sharp elevation of total serum IgE to wheezing dyspnea or status asthmaticus. Serologic assays that are of major value in diagnosis of ABPA include elevation of total serum IgE--not all of which is directed against Aspergillus fumigatus, precipitating antibodies to A. fumigatus--unless the patient is in remission, and elevated serum IgE-A. fumigatus and IgG-A. fumigatus compared to serum from patients with asthma with immediate cutaneous reactivity to A. fumigatus but without evidence of ABPA. Five stages have been identified which reflect the time of recognition of ABPA and disease activity. They are Acute, Remission, Recurrent Exacerbation, Corticosteroid-Dependent Asthma, and Fibrotic. Stage I (Acute) patients have the classic clinical, serologic, and radiologic features of ABPA. Stage II (Remission) occurs after prednisone has resulted in resolution of the chest infiltrate and can be tapered and discontinued for 6 months without new infiltrates. Stage III (Exacerbation) occurs when a new roentgenographic infiltrate occurs associated with elevation of total serum IgE. Stage IV (Corticosteroid-Dependent Asthma) is present when repeated attempts to discontinue prednisone results in severe wheezing that cannot be prevented with other therapy. Some Stage IV patients continue to develop new ABPA infiltrates. Stage V (Fibrotic) patients have irreversible obstructive and restrictive pulmonary function abnormalities and may present or progress to respiratory failure and death.

Use of linear tomography to confirm the diagnosis of allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) has been recognized increasingly in the past few years. In minimal disease, plain chest films may be insensitive. Early detection of pulmonary involvement may help prevent irreversible damage to the lungs and bronchi. Bronchography, while both sensitive and specific, is not without hazard, particularly to the asthmatic patient. We evaluated the usefulness of linear tomography in confirming ABPA prior to initiation of corticosteroid therapy. We find that tomography is a simple, noninvasive instrument for detecting the presence of or proving the absence of the earliest manifestations of ABPA.

Roentgenographic and clinical staging of allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is a disease of asthmatics that follows a protracted course. When ABPA is treated with high dose corticosteroids, it presents a difficult problem in clinical management. Five stages, based on clinical, roentgenographic, and immunologic criteria, have been identified as follows: (I) acute, (II) remission, (III) exacerbation, (IV) corticosteroid-dependent asthma, and (V) pulmonary fibrosis. We studied 24 ABPA patients actively followed for up to 11 years at our institution. We conclude that while there are no unique roentgenographic findings to define a particular stage, clinicoroentgenographic staging does aid in therapeutic management. Two major roentgenographic contributions are (1) to establish the diagnosis by demonstrating proximal bronchiectasis, and (2) to provide a baseline for an individual patient against which to monitor progressive changes and remissions.

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.

Allergic bronchopulmonary aspergillosis in cystic fibrosis

One hundred patients with CF were screened for ABPA. Forty-eight male patients and 52 female patients with age range of 2 to 34 yr (mean 14.2) were studied. Patients were evaluated for skin reactivity and serum precipitating antibodies to Af, predominant sputum organisms, total blood eosinophil levels, total serum IgE, and Af-specific IgE and IgG, as well as abnormalities of pulmonary function and chest x-ray films. Careful evaluation of all patients with CF demonstrated that 10% had features indicative of ABPA, which is another potentially destructive pulmonary disorder. Thus careful evaluation of patients with CF, especially those with asthma, may be rewarding in uncovering a disorder that may slow progression of CF when it is appropriately treated.

Allergic bronchopulmonary aspergillosis in corticosteroid-dependent asthmatics

Forty-two corticosteroid-dependent asthmatics were studied to determine whether their underlying disease might be allergic bronchopulmonary aspergillosis (ABPA). The clinical and laboratory characteristics studied included age, sex, atopic status, mean corticosteroid doses, skin tests to Aspergillus fumigatus (Af), precipitins to Af, total serum IgE, and chest roentgenograms. Twelve patients had four or more of the seven primary criteria used and were considered as the ABPA suspect group. Further studies identified three patients who were considered to have definite ABPA and an additional three patients with probable ABPA. This study suggests that previously undiagnosed ABPA can be detected in populations of corticosteroid dependent asthmatics. Corticosteroid therapy may mask ABPA, and serial evaluations of these patients may be of value in detecting additional cases of the disease.