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Agarwal R, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Aggarwal AN. Allergic Bronchopulmonary Aspergillosis. Clin Chest Med 2022; 43:99-125. [DOI: 10.1016/j.ccm.2021.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Total unilateral pulmonary collapse secondary to allergic bronchopulmonary aspergillosis: a case series of an unusual cause of complete atelectasis. BMC Pulm Med 2021; 21:425. [PMID: 34952578 PMCID: PMC8709957 DOI: 10.1186/s12890-021-01789-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 12/07/2021] [Indexed: 12/14/2022] Open
Abstract
Background Allergic bronchopulmonary aspergillosis (ABPA) is a bronchopulmonary disease caused by a complex hypersensitivity to Aspergillus and is usually associated with underlying respiratory diseases such as asthma or cystic fibrosis. Mucus plugging can lead to segmental or lobar atelectasis, but complete lung atelectasis has been exceptionally reported in the literature, making it difficult to diagnose. The diagnosis of ABPA may however be suggested in patients without known predisposing respiratory disorder, even in the absence of other relevant radiographic findings. Case presentation We report five cases of total unilateral lung collapse secondary to ABPA in 70–81-year-old women. Two of them had a past history of ABPA, while total unilateral lung collapse was the first sign of the disease in the other three patients, contributing to the initial misdiagnosis. Flexible bronchoscopy was initially performed to remove mucus plugs from the obstructed airways but was inefficient in four cases. Corticosteroid and/or antifungal treatment was needed. Conclusion ABPA can cause total unilateral lung collapse even in patients without known underlying chronic respiratory disease, making the diagnosis difficult. Flexible bronchoscopy should be considered when lung collapse is associated with respiratory distress but corticosteroids are the mainstay treatment for ABPA.
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Iqbal N, Amir Sheikh MD, Jabeen K, Awan S, Irfan M. "Allergic bronchopulmonary aspergillosis misdiagnosed as smear negative pulmonary tuberculosis; a retrospective study from Pakistan". Ann Med Surg (Lond) 2021; 72:103045. [PMID: 34815860 PMCID: PMC8591471 DOI: 10.1016/j.amsu.2021.103045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/30/2022] Open
Abstract
Background Undiagnosed allergic bronchopulmonary aspergillosis (ABPA) can lead to chronic persistent symptoms. In country like Pakistan where tuberculosis (TB) is endemic, a significant proportion of ABPA patients are misdiagnosed as smear negative TB before reaching a diagnosis of ABPA due to chronicity of symptoms.This lead to empiric use of ATT(Anti-tuberculous therapy) and delay in primary diagnosis. The aim of the study is to determine such proportion of ABPA patients. Material and methods This retrospective study was conducted at the outpatient pulmonology clinic of a tertiary care hospital in Karachi, Pakistan from January 2017 to December 2018. Xpert MTB/Rif, TB smear and culture were performed in all patients to rule out active TB. Results A total 167 of ABPA patients were included. Mean age of the patients was 41.9 ± 13.0 years, 91(54.5%) were female and 71 (42.5%) patients had received ATT in past. Out of these 71 patients, 63 (88.7%) patients were diagnosed as smear negative TB and received empiric ATT. Among 63 patients, 52 (82.5%) patient had received ATT once, 8 (12.6%) twice and 3 (4.7%) patients had received empiric ATT thrice. Of these 27 (16.16%) patients had already developed long term complications at the time of diagnosis of ABPA and 17 (62.96%) patients were in empiric TB treatment group. Conclusion Patient with ABPA frequently received empiric ATT as smear negative TB in high TB burden country. This results in over diagnosis of TB and unnecessary use of global resource. When Gene Xpert negative alternate diagnosis should be considered. Allergic bronchopulmonary aspergillosis (ABPA) can lead to chronic persistent symptoms. In country like Pakistan where tuberculosis (TB) is endemic, a significant proportion of ABPA patients are misdiagnosed as smear negative TB before reaching a diagnosis of ABPA due to chronicity of symptoms which leads to empiric use of ATT. So the aim of the study is to determine such proportion of ABPA patients in country where TB is endemic.
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Affiliation(s)
- Nousheen Iqbal
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Aga Khan University, Karachi, Pakistan.,Jinnah Medical and Dental College, Karachi, Pakistan
| | | | - Kauser Jabeen
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Muhammad Irfan
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Aga Khan University, Karachi, Pakistan
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Mortezaee V, Mahdaviani SA, Pourabdollah M, Hassanzad M, Mirenayat MS, Mehrian P, Behnampour N, Yazdani Charati J, Peirovi Z, Sharifynia S, Seyedmousavi S, Hedayati MT. Diagnosis of allergic bronchopulmonary aspergillosis in patients with persistent allergic asthma using three different diagnostic algorithms. Mycoses 2020; 64:272-281. [PMID: 33219548 DOI: 10.1111/myc.13217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/13/2020] [Accepted: 11/13/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) has been reported in various degrees among patients with persistent allergic asthma (PAA). Currently, there is no gold standard approach for diagnosis of ABPA. OBJECTIVES In the current study, we aimed the evaluation of three different mainly used algorithms as Rosenberg & Patterson (A), ISHAM Working Group (B) and Greenberger (C) for diagnosis of ABPA in 200 patients with underlying PAA. METHODS All patients were evaluated using Aspergillus skin prick test (SPTAf), Aspergillus-specific IgE (sIgEAf) and IgG (sIgGAf), total IgE (tIgE), pulmonary function tests, radiological findings and peripheral blood eosinophil count. The prevalence rate of ABPA in PAA patients was estimated by three diagnostic criteria. We used Latent Class Analysis for the evaluation of different diagnostic parameters in different applied ABPA diagnostic algorithms. RESULTS Aspergillus sensitisation was observed in 30 (15.0%) patients. According to algorithms A, B and C, nine (4.5%), six (3.0%) and 11 (5.5%) of patients were diagnosed with ABPA, respectively. The sensitivity and specificity of criteria B and C were (55.6% and 99.5%) and (100.0% and 98.9%) respectively. sIgEAf and sIgGAf showed the high significant sensitivity. The performance of algorithm A, in terms of sensitivity and specificity, was somewhat better than algorithm B. CONCLUSION Our study demonstrated that the sensitivity of different diagnostic algorithms could change the prevalence rate of ABPA. We also found that all of three criteria resulted an adequate specificity for ABPA diagnosis. A consensus patterns combining elements of all three criteria may warrant a better diagnostic algorithm.
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Affiliation(s)
- Vida Mortezaee
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Seyed Alireza Mahdaviani
- Paediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shaheed Beheshti University of Medical Sciences, Tehran, Iran
| | - Mihan Pourabdollah
- Paediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shaheed Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Hassanzad
- Paediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shaheed Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Sadat Mirenayat
- Lung Transplantation Research Center (LTRC), National Research Institute of Tuberculosis and Lung Diseases (NIRTLD), Shaheed Beheshti University of Medical Sciences, Tehran, Iran
| | - Payam Mehrian
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shaheed Beheshti University of Medical Sciences, Tehran, Iran
| | - Naser Behnampour
- Department of Biostatistics, Faculty of Health, Golestan University of Medical Sciences, Gorgan, Iran
| | - Jamshid Yazdani Charati
- Department of Biostatistics, Faculty of Health, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zahra Peirovi
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shaheed Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Sharifynia
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyedmojtaba Seyedmousavi
- Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad T Hedayati
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.,Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
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Saxena P, Choudhary H, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Garg M, Saikia B, Aggarwal AN, Chakrabarti A, Agarwal R. Which Are the Optimal Criteria for the Diagnosis of Allergic Bronchopulmonary Aspergillosis? A Latent Class Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:328-335.e1. [PMID: 32890756 DOI: 10.1016/j.jaip.2020.08.043] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/29/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The ideal criteria for diagnosing allergic bronchopulmonary aspergillosis (ABPA) remain unknown because of the lack of a criterion standard. Latent class analysis using a probabilistic modeling technique can circumvent the need for a reference standard. OBJECTIVE To compare the diagnostic performance of various criteria used for evaluating ABPA. METHODS We prospectively enrolled consecutive cases of bronchial asthma and performed a series of investigations used for the diagnosis of ABPA. We used latent class analysis to analyze the performance of various existing and novel diagnostic criteria. RESULTS Of the 543 subjects (mean age, 37 years; 319 women), 338 (62.2%) and 205 (37.8%) were labeled as "mild-to-moderate" and "severe" asthma cases, respectively. The subjects with severe asthma had a longer duration of asthma and a higher number of exacerbations in the previous year. The prevalence of Aspergillus fumigatus sensitization was 41% and 30%, using the A fumigatus-specific IgE and skin test, respectively. The prevalence of ABPA was 16%, using both the Rosenberg-Patterson and the International Society for Human and Animal Mycology (ISHAM)-ABPA Working Group criteria. The ISHAM criteria were slightly more sensitive (89% vs 81%) and specific (99% vs 98%) than the Patterson criteria. We obtained optimal diagnostic performance by altering the existing ISHAM criteria (serum total IgE >500 international units/mL, excluding the skin test, and using computed tomography of thorax instead of chest radiograph). CONCLUSIONS The ISHAM-ABPA Working Group criteria were only marginally better than the Patterson criteria in diagnosing ABPA among patients with asthma younger than 66 years. The diagnostic performance however improved by modifying the prevailing ISHAM criteria, but with increased cost.
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Affiliation(s)
- Puneet Saxena
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Hansraj Choudhary
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India; Department of Medical Microbiology, PGIMER, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mandeep Garg
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India; Department of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India
| | - Biman Saikia
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India; Department of Immunopathology, PGIMER, Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India; Department of Medical Microbiology, PGIMER, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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Russo A, Tiseo G, Falcone M, Menichetti F. Pulmonary Aspergillosis: An Evolving Challenge for Diagnosis and Treatment. Infect Dis Ther 2020; 9:511-524. [PMID: 32638227 PMCID: PMC7339098 DOI: 10.1007/s40121-020-00315-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Indexed: 02/07/2023] Open
Abstract
Aspergillus is a mold that may lead to different clinical pictures, from allergic to invasive disease, depending on the patient’s immune status and structural lung diseases. Chronic pulmonary aspergillosis is an infection with a locally invasive presentation, reported especially in patients with chronic pulmonary disease, while aspergilloma is typically found in patients with previously formed cavities in the lungs. Allergic bronchopulmonary aspergillosis is due to a hypersensitivity reaction to Aspergillus antigens and is more frequently described in patients with moderate-severe asthma or cystic fibrosis. Invasive pulmonary aspergillosis mainly occurs in patients with neutropenia or immunodeficiency, but has increasingly been recognized as an emerging disease of non-neutropenic patients. The significance of this infection has dramatically increased in recent years, considering the high number of patients with an impaired immune state associated with the management and treatment of neoplasm, solid or hematological transplantation, autoimmune diseases, and inflammatory conditions. Moreover, prolonged steroid treatment is recognized as an important risk factor, especially for invasive disease. In this setting, critically ill patients admitted to intensive care units and/or with chronic obstructive pulmonary disease could be at higher risk for invasive infection. This review provides an update on the clinical features and risk factors of pulmonary aspergillosis. Current approaches for the diagnosis, management, and treatment of these different forms of pulmonary aspergillosis are discussed.
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Affiliation(s)
- Alessandro Russo
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Giusy Tiseo
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marco Falcone
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesco Menichetti
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Allergic Bronchopulmonary Aspergillosis: A Disease that Raises Many Questions. Arch Bronconeumol 2020; 56:424-425. [PMID: 32247667 DOI: 10.1016/j.arbres.2019.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/18/2019] [Accepted: 09/25/2019] [Indexed: 11/22/2022]
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Lu HW, Mao B, Wei P, Jiang S, Wang H, Li CW, Ji XB, Gu SY, Yang JW, Liang S, Cheng KB, Bai JW, Cao WJ, Jia XM, Xu JF. The clinical characteristics and prognosis of ABPA are closely related to the mucus plugs in central bronchiectasis. CLINICAL RESPIRATORY JOURNAL 2019; 14:140-147. [PMID: 31758867 PMCID: PMC7028037 DOI: 10.1111/crj.13111] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/08/2019] [Accepted: 11/08/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The characteristics of Allergic Bronchopulmonary Aspergillosis (ABPA) based on its radiological classification is still unclear. OBJECTIVES To investigate the clinical significances of ABPA patients with central bronchiectasis (ABPA-CB) by different radiological classifications of mucus plugs. METHODS ABPA-CB patients from a pulmonary hospital between 2008 and 2015 were retrospectively included and analysed. According to the chest imaging in their first visit to physician, the ABPA-CB patients were divided into two groups based on the presence of high-attenuation mucus (HAM) or low-attenuation mucus (LAM). The primary endpoint was ABPA relapse within 1 year since the glucocorticoid withdrawal. The relationship between the imaging findings and the clinical prognosis was illuminated. RESULTS A total of 125 ABPA patients were analysed in this study. Compared to the LAM group, the HAM group presented higher blood eosinophil cells counts, higher rates of Aspergillus detection isolated in sputum and expectoration of brownish-black mucus plugs, more affected lobes and segments, poorer pulmonary function and higher rate of relapse. CONCLUSIONS The clinical characteristics and prognosis of ABPA-CB patients are closely related to its radiological phenotype of mucus plugs in the central bronchiectasis. Clinicians should promote a diversity of personalized treatments for different patients with different radiological characteristics.
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Affiliation(s)
- Hai-Wen Lu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bei Mao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping Wei
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Sen Jiang
- Department of Radiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong Wang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Cheng-Wei Li
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiao-Bing Ji
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shu-Yi Gu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jia-Wei Yang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shuo Liang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ke-Bin Cheng
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiu-Wu Bai
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei-Jun Cao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xin-Ming Jia
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Diagnosing Allergic Bronchopulmonary Aspergillosis: A Review. Cureus 2019; 11:e4550. [PMID: 31275774 PMCID: PMC6592842 DOI: 10.7759/cureus.4550] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Dr. Hinson and his colleagues first described allergic bronchopulmonary aspergillosis (ABPA) in 1952. Later in 1977, Rosenberg proposed a diagnostic criteria for ABPA that even today remains widely acknowledged. Despite these steps taken, there still isn't a standardized diagnostic criteria set for ABPA although many have been proposed by various physicians over the years. ABPA is a condition caused by hypersensitivity to Aspergillus fumigatus antigens. It is seen most commonly in patients with either asthma or cystic fibrosis. In susceptible hosts, repeated inhalation of Aspergillus spores can cause an allergic response. Although a standardized diagnostic criteria is required, there is no single test that establishes the diagnosis other than a demonstration of central bronchiectasis (CB) with normal tapering bronchi, a feature that is still considered pathognomonic of ABPA. Because of lack of standardized diagnostic criteria and screening, even today ABPA is under diagnosed and often times treatment for it is delayed. This can lead to complications in patients like pulmonary fibrosis, bronchiectasis with chronic sputum production, and increasingly severe persistent asthma with loss of lung function. For this alone, it becomes imperative that the diagnostic criteria guidelines need to be reviewed and standardized preferably with the help of larger research studies. In the following review article, we address the epidemiology, pathophysiology, and the current cumulative view regarding the diagnosis of ABPA.
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Affiliation(s)
- Avani R Patel
- Internal Medicine, Northern California Kaiser Permanente, Fremont, USA
| | - Amar R Patel
- Internal Medicine, Northern California Kaiser Permanente, Fremont, USA
| | - Shivank Singh
- Internal Medicine, Southern Medical University, Guangzhou, CHN
| | - Shantanu Singh
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
| | - Imran Khawaja
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
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Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Treating Allergic Bronchopulmonary Aspergillosis: A Review. Cureus 2019; 11:e4538. [PMID: 31263646 PMCID: PMC6592456 DOI: 10.7759/cureus.4538] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder that results from a hypersensitivity reaction to the fungi Aspergillus fumigatus (Af). It presents with pulmonary infiltrates and bronchiectasis. Past research studies on ABPA have led to the conclusion that it is both underdiagnosed and much more prevalent than previously assumed. The underdiagnosing of ABPA is due to a lack of consensus regarding diagnosis and treatment. Complications that result from delay in treatment for ABPA are pulmonary fibrosis, bronchiectasis with chronic sputum production, and severe persistent asthma with loss of lung function. Because of this, it becomes imperative that ABPA treatment guidelines are reviewed and more thoroughly evaluated regarding their efficacy. The following article addresses the epidemiology, the pathophysiology, and the treatment of ABPA. The treatment is studied in detail regarding the types of medications used and their proven clinical impact on patients according to past research studies. The aim of this article is to address the current need for larger clinical trials in order to learn more and establish more formal treatment protocols for ABPA.
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Affiliation(s)
- Avani R Patel
- Internal Medicine, Northern California Kaiser Permanente, Fremont, USA
| | - Amar R Patel
- Internal Medicine, Northern California Kaiser Permanente, Fremont, USA
| | - Shivank Singh
- Internal Medicine, Southern Medical University, Guangzhou, CHN
| | - Shantanu Singh
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
| | - Imran Khawaja
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
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Al-Saleh AA, Farid E, Makhlooq M, Mahdi M, Reda M, Zaid T, Al-Alawi S, Panjwani A, Salman N, Ali HR, Bindayna K. Allergic aspergillosis in asthmatic patients in a tertiary hospital in the Kingdom of Bahrain. J Lab Physicians 2019; 11:373-381. [PMID: 31929707 PMCID: PMC6943863 DOI: 10.4103/jlp.jlp_42_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND INFORMATION: Aspergillosis is an alarming complication in asthma, leading to worsening symptoms and irreversible lung damage. It is underdiagnosed among asthmatics worldwide, especially in our geographical region. AIM: This research was aimed to shed some light on the prevalence of Aspergillus sensitization and allergic bronchopulmonary aspergillosis (ABPA) in asthmatic patients in the Kingdom of Bahrain. IMPORTANCE: This project has never been conducted in the region and hopefully will lead to a better care for asthmatics. METHODOLOGY: Our study population consisted of adult outpatients visiting the pulmonary and chest diseases clinic at Al-Salmaniya Medical Complex (SMC); the main inclusion condition was manifesting respiratory distress symptoms related to one or more respiratory tract diseases. 152 individuals were selected; the study group consisted of 119 asthmatic patients manifesting respiratory distress. The control group consisted of 33 nonasthmatic patients that manifested pulmonary distress symptoms due to respiratory tract diseases other than asthma like chronic obstructive pulmonary disease, bronchitis, among others. Sera samples were collected in SMC and analyzed via Phadia-250 fluoro-enzyme-immunoassay to determine the levels of Aspergillus fumigatus-specific IgE. The rAsp f1 antigen was used against IgE. RESULTS: Our results indicated a 16% prevalence of A. fumigatus sensitization in asthmatics; also, 75.6% of asthmatics were sensitized to pollen grains, and 22.3% reported one or many food allergies. Furthermore, details of patients with significant levels of A. fumigatus- specific IgE were analyzed, and ABPA prevalence was estimated to be 10.1% in asthmatics. CONCLUSION: Increasing awareness toward these indolent diseases is required, as well as, more efforts in determining the burden of aspergillosis in other parts of the region.
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Affiliation(s)
- Abdullah A Al-Saleh
- Department of Microbiology, Immunology and Infectious Diseases, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Eman Farid
- Department of Microbiology, Immunology and Infectious Diseases, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain.,Department of Pathology, Immunology Laboratory, Al-Salmaniya Medical Complex, Manama, Bahrain
| | - Mohammed Makhlooq
- Department of Internal Medicine, Pulmonary and Chest Diseases Clinic, Al-Salmaniya Medical Complex, Manama, Bahrain
| | - Munner Mahdi
- Department of Internal Medicine, Pulmonary and Chest Diseases Clinic, Al-Salmaniya Medical Complex, Manama, Bahrain
| | - Mohammed Reda
- Department of Internal Medicine, Pulmonary and Chest Diseases Clinic, Al-Salmaniya Medical Complex, Manama, Bahrain
| | - Thuraya Zaid
- Department of Internal Medicine, Pulmonary and Chest Diseases Clinic, Al-Salmaniya Medical Complex, Manama, Bahrain
| | - Sugra Al-Alawi
- Department of Internal Medicine, Pulmonary and Chest Diseases Clinic, Al-Salmaniya Medical Complex, Manama, Bahrain
| | - Amit Panjwani
- Department of Internal Medicine, Pulmonary and Chest Diseases Clinic, Al-Salmaniya Medical Complex, Manama, Bahrain
| | - Nasser Salman
- Department of Internal Medicine, Pulmonary and Chest Diseases Clinic, Al-Salmaniya Medical Complex, Manama, Bahrain
| | - Hussien R Ali
- Department of Internal Medicine, Pulmonary and Chest Diseases Clinic, Al-Salmaniya Medical Complex, Manama, Bahrain
| | - Khalid Bindayna
- Department of Microbiology, Immunology and Infectious Diseases, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
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Chan ED, Wooten WI, Hsieh EW, Johnston KL, Shaffer M, Sandhaus RA, van de Veerdonk F. Diagnostic evaluation of bronchiectasis. RESPIRATORY MEDICINE: X 2019. [DOI: 10.1016/j.yrmex.2019.100006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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13
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The spectrum of pulmonary aspergillosis. Respir Med 2018; 141:121-131. [PMID: 30053957 DOI: 10.1016/j.rmed.2018.06.029] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/26/2018] [Accepted: 06/29/2018] [Indexed: 11/24/2022]
Abstract
Notable progress has been made in the past years in the classification, diagnosis and treatment of pulmonary aspergillosis. New criteria were proposed by the Working Group of the International Society for Human and Animal Mycology (ISHAM) for the diagnosis of allergic bronchopulmonary aspergillosis (ABPA). The latest classification of chronic pulmonary aspergillosis (CPA) suggested by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) has become widely accepted among clinicians. Subacute invasive pulmonary aspergillosis is now considered a type of CPA, yet it is still diagnosed and treated similarly to invasive pulmonary aspergillosis (IPA). Isavuconazole, an extended-spectrum triazole, has recently been approved by the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the treatment of IPA. The most recent Infectious Diseases Society of America (IDSA) guidelines strongly recommend reducing mold exposure to patients at high risk for pulmonary aspergillosis. The excessive relapse rate following discontinuation of therapy remains a common reality to all forms of this semi-continuous spectrum of diseases. This highlights the need to continuously reassess patients and individualize therapy accordingly. Thus far, the duration of therapy and the frequency of follow-up have to be well characterized.
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Agarwal R, Sehgal IS, Dhooria S, Aggarwal AN. Developments in the diagnosis and treatment of allergic bronchopulmonary aspergillosis. Expert Rev Respir Med 2016; 10:1317-1334. [PMID: 27744712 DOI: 10.1080/17476348.2016.1249853] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder characterized by recurrent episodes of wheezing, fleeting pulmonary opacities and bronchiectasis. It is the most prevalent of the Aspergillus disorders with an estimated five million cases worldwide. Despite six decades of research, the pathogenesis, diagnosis and treatment of this condition remains controversial. The International Society for Human and Animal Mycology has formed a working group to resolve the controversies around this entity. In the year 2013, this group had proposed new criteria for diagnosis and staging, and suggested a treatment protocol for the management of this disorder. Since then, several pieces of new evidence have been published in the investigation and therapeutics of this condition. Areas covered: A non-systematic review of the available literature was performed. We summarize the current evidence in the evaluation and treatment of this enigmatic disorder. We suggest modifications to the existing criteria and propose a new scoring system for the diagnosis of ABPA. Expert commentary: All patients with asthma and cystic fibrosis should routinely be screened for ABPA using A. fumigatus-specific IgE levels. Glucocorticoids should be used as the first-line of therapy in ABPA, and itraconazole reserved in those with recurrent exacerbations and glucocorticoid-dependent disease.
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Affiliation(s)
- Ritesh Agarwal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Inderpaul S Sehgal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Sahajal Dhooria
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Ashutosh N Aggarwal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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Tanimoto H, Fukutomi Y, Yasueda H, Takeuchi Y, Saito A, Watai K, Sekiya K, Tsuburai T, Asano K, Taniguchi M, Akiyama K. Molecular-based allergy diagnosis of allergic bronchopulmonary aspergillosis in Aspergillus fumigatus-sensitized Japanese patients. Clin Exp Allergy 2016; 45:1790-800. [PMID: 26118958 DOI: 10.1111/cea.12590] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 05/11/2015] [Accepted: 06/07/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Distinguishing between patients with allergic bronchopulmonary aspergillosis (ABPA) and Aspergillus fumigatus (Af)-sensitized asthmatic patients without ABPA is sometimes difficult owing to the IgE-cross-reactivity between Af and other fungal allergens. OBJECTIVE To establish the usefulness of molecular-based allergy diagnostics using allergen components from Af in distinguishing ABPA from Af-sensitized asthma without ABPA. METHODS Sera from Japanese patients with ABPA (n = 53) and Af-sensitized asthma without ABPA (n = 253) were studied. The levels of IgE and IgG antibodies to allergen components from Af and IgE antibodies to different fugal allergen extracts were measured by ImmunoCAP. Comorbid atopic dermatitis (AD) was taken into consideration in the sensitization profile analysis. RESULTS Patients with ABPA possessed significantly higher levels of IgE antibodies to Asp f 1, and Asp f 2 than asthmatic patients without ABPA. The areas under the receiver operating characteristic curves for the levels of IgE to Asp f 1 and Asp f 2 as diagnostic markers of ABPA were 0.75 and 0.78, respectively. The presence of IgE positivity to Asp f 1 and/or Asp f 2 resulted in increased sensitivity while losing little specificity. Comorbid AD was associated with higher levels of IgE to Asp f 6 (manganese superoxide dismutase from Af, a ubiquitous pan-allergen in fungi) and low but positive levels of IgE to other Af-components, which hampered the serological discrimination of ABPA. CONCLUSIONS AND CLINICAL RELEVANCE The levels of IgE to Asp f 1 and/or Asp f 2 can effectively differentiate ABPA from Af-sensitized asthma, suggesting that the amounts of IgE specific for these molecules are markers for genuine Af-sensitization in ABPA. However, comorbid AD must be taken into consideration in the interpretation of high IgE to Asp f 6. Establishing of IgE-sensitization profiles using panel of Af-allergen components provides valuable information for distinguishing genuine vs. cross-reactive sensitization in Af-sensitized patients.
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Affiliation(s)
- H Tanimoto
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - Y Fukutomi
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - H Yasueda
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - Y Takeuchi
- Division of Respiratory Medicine and Clinical Allergy, Fujita Health University, Toyoake, Aichi, Japan
| | - A Saito
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - K Watai
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - K Sekiya
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - T Tsuburai
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - K Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - M Taniguchi
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - K Akiyama
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
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Shah A, Panjabi C. Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2016; 8:282-97. [PMID: 27126721 PMCID: PMC4853505 DOI: 10.4168/aair.2016.8.4.282] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 05/15/2015] [Indexed: 01/30/2023]
Abstract
In susceptible individuals, inhalation of Aspergillus spores can affect the respiratory tract in many ways. These spores get trapped in the viscid sputum of asthmatic subjects which triggers a cascade of inflammatory reactions that can result in Aspergillus-induced asthma, allergic bronchopulmonary aspergillosis (ABPA), and allergic Aspergillus sinusitis (AAS). An immunologically mediated disease, ABPA, occurs predominantly in patients with asthma and cystic fibrosis (CF). A set of criteria, which is still evolving, is required for diagnosis. Imaging plays a compelling role in the diagnosis and monitoring of the disease. Demonstration of central bronchiectasis with normal tapering bronchi is still considered pathognomonic in patients without CF. Elevated serum IgE levels and Aspergillus-specific IgE and/or IgG are also vital for the diagnosis. Mucoid impaction occurring in the paranasal sinuses results in AAS, which also requires a set of diagnostic criteria. Demonstration of fungal elements in sinus material is the hallmark of AAS. In spite of similar histopathologic features, co-existence of ABPA and AAS is still uncommon. Oral corticosteroids continue to be the mainstay of management of allergic aspergillosis. Antifungal agents play an adjunctive role in ABPA as they help reduce the fungal load. Saprophytic colonization in cavitary ABPA may lead to aspergilloma formation, which could increase the severity of the disease. The presence of ABPA, AAS, and aspergilloma in the same patient has also been documented. All patients with Aspergillus-sensitized asthma must be screened for ABPA, and AAS should always be looked for.
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Affiliation(s)
- Ashok Shah
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India.
| | - Chandramani Panjabi
- Department of Respiratory Medicine, Mata Chanan Devi Hospital, New Delhi, India
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17
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Dhooria S, Agarwal R. Diagnosis of allergic bronchopulmonary aspergillosis: a case-based approach. Future Microbiol 2015; 9:1195-208. [PMID: 25405888 DOI: 10.2217/fmb.14.74] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis is a pulmonary disease occurring in patients with asthma or cystic fibrosis, consequent to a dysregulated immune response to inhaled Aspergillus conidia. The usual presentation is with poorly controlled asthma. Patients may also present with expectoration of mucus plugs, hemoptysis, constitutional symptoms and radiological opacities. Patients may experience smoldering lung destruction despite well-controlled asthma. With emerging data, the diagnostic criteria transcribed by an International Expert Committee in 2013 are the latest evidence-based guidelines. Herein, we utilize a case-based approach to elaborate on the diagnosis of this disease. The review intends to provide a lucid understanding of the diagnostic process for the expert as well as the primary physician, involved in management of this enigmatic disorder.
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Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Patterson KC, Strek ME. Diagnosis and treatment of pulmonary aspergillosis syndromes. Chest 2015; 146:1358-1368. [PMID: 25367472 DOI: 10.1378/chest.14-0917] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Both inherited and acquired immunodeficiency and chronic pulmonary disease predispose to the development of a variety of pulmonary syndromes in response to Aspergillus, a fungus that is ubiquitous in the environment. These syndromes include invasive aspergillosis, which is now recognized to occur in patients with critical illness without neutropenia and in those with mild degrees of immunosuppression, including from corticosteroid use in the setting of COPD. Chronic pulmonary aspergillosis includes simple aspergilloma, which is occasionally complicated by life-threatening hemoptysis, and progressive destructive cavitary disease requiring antifungal therapy. Allergic bronchopulmonary aspergillosis occurs almost exclusively in patients with asthma or cystic fibrosis. Recent advances in each of these syndromes include a greater understanding of the underlying pathophysiology and hosts at risk; improved diagnostic algorithms; and the availability of more effective and well-tolerated therapies. Improvement in outcomes for Aspergillus pulmonary syndromes requires that physicians recognize the varied and sometimes subtle presentations, be aware of populations at risk of illness, and institute potentially life-saving therapies early in the disease course.
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Affiliation(s)
- Karen C Patterson
- From the The Pulmonary, Allergy and Critical Care Division, University of Pennsylvania, Pennsylvania, PA.
| | - Mary E Strek
- The Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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Greenberger PA, Bush RK, Demain JG, Luong A, Slavin RG, Knutsen AP. Allergic bronchopulmonary aspergillosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2014; 2:703-8. [PMID: 25439360 PMCID: PMC4306287 DOI: 10.1016/j.jaip.2014.08.007] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 01/03/2023]
Abstract
There remains a lack of agreement on diagnostic criteria and approaches to treatment of patients with allergic bronchopulmonary aspergillosis (ABPA). The results of a survey of American Academy of Allergy, Asthma, & Immunology members regarding these 2 issues are presented and compared for concordance with published recommendations. The literature was reviewed for pertinent reports, and an electronic survey was conducted of American Academy of Allergy, Asthma, & Immunology members and fellows regarding diagnostic criteria, numbers of patients evaluated for ABPA, and treatment approaches. From 508 respondents to the survey sent to 5155 US physicians in the American Academy of Allergy, Asthma, & Immunology database of members and fellows, 245 health professionals (48%) had treated at least 1 patient with ABPA in the previous year. For the diagnosis of ABPA, there was a difference in the threshold concentration of total serum IgE because 44.9% used ≥417 kU/L, whereas 42.0% used ≥1000 kU/L. Analysis of these findings suggests that ABPA might be underdiagnosed. With regard to pharmacotherapy, oral steroids were recommended for 97.1% of patients and oral steroids plus inhaled corticosteroids plus antifungal agent were used with 41.2% of patients. The armamentarium for treatment of ABPA includes oral corticosteroids as the initial treatment with inhaled corticosteroids used for management of persistent asthma. Azoles remain adjunctive. Published experience with omalizumab has been limited.
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MESH Headings
- Administration, Inhalation
- Administration, Oral
- Adrenal Cortex Hormones/administration & dosage
- Adrenal Cortex Hormones/adverse effects
- Allergy and Immunology/standards
- Antifungal Agents/adverse effects
- Antifungal Agents/therapeutic use
- Aspergillosis, Allergic Bronchopulmonary/blood
- Aspergillosis, Allergic Bronchopulmonary/diagnosis
- Aspergillosis, Allergic Bronchopulmonary/epidemiology
- Aspergillosis, Allergic Bronchopulmonary/genetics
- Aspergillosis, Allergic Bronchopulmonary/immunology
- Aspergillosis, Allergic Bronchopulmonary/microbiology
- Aspergillosis, Allergic Bronchopulmonary/therapy
- Biomarkers/blood
- Genetic Predisposition to Disease
- Guideline Adherence
- Health Care Surveys
- Humans
- Immunoglobulin E/blood
- Practice Guidelines as Topic
- Practice Patterns, Physicians'
- Predictive Value of Tests
- Risk Factors
- Treatment Outcome
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Affiliation(s)
- Paul A Greenberger
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Robert K Bush
- Division of Allergy-Immunology, Department of Medicine, University of Wisconsin, Madison, Wis
| | - Jeffrey G Demain
- Allergy, Asthma and Immunology Center of Alaska, University of Washington, Anchorage, Alaska
| | - Amber Luong
- Otolaryngology-Head and Neck Surgery, University of Texas Medical School at Houston, Houston, Texas
| | - Raymond G Slavin
- Section of Allergy-Immunology, Division of Infectious Diseases, Department of Internal Medicine, St Louis University, St Louis, Mo
| | - Alan P Knutsen
- Division of Allergy-Immunology, Department of Pediatrics, St Louis University, St Louis, Mo
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