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Zhang LS, Wu YF, Lu HW, Wang L, Xu JY, Gu SY, Mao B, Yu L, Li JX, Weng D, Xu JF. Fractional exhaled nitric oxide, a potential biomarker for evaluating glucocorticoids treatment and prognosis in allergic bronchopulmonary aspergillosis. Ann Allergy Asthma Immunol 2024; 133:168-176.e1. [PMID: 38777120 DOI: 10.1016/j.anai.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is characterized by enhanced TH2 inflammatory response. Fractional exhaled nitric oxide (FeNO) measurement has been used as a valuable tool in predicting the development and management of asthma, another typical TH2 inflammation. However, the clinical significance of FeNO in ABPA remains unclear. OBJECTIVE To investigate the association between FeNO and the prognosis of patients with ABPA to provide a basis for the use of FeNO in evaluating the efficacy of glucocorticoids in ABPA treatment. METHODS This study comprised 2 parts; 58 patients were enrolled in the retrospective study. Clinical indexes in patients with different prognoses were compared, and receiver operating characteristic curve analysis was used to determine the threshold value. The prospective observational study involved 61 patients who were regularly followed up at 4 to 6 weeks and 6 months since the initial treatment. Patients were grouped on the basis of baseline FeNO values; correlation analysis was performed in the clinical data. RESULTS Different prognoses were observed between patients with high and low baseline FeNO values, with a threshold value of 57 parts per billion. The percentage of Aspergillus fumigatus-specific IgE, percentage of positive A fumigatus-specific IgG, and relapse/exacerbation rate differed significantly between the high and low FeNO groups. Patients with higher FeNO needed longer treatment duration and showed shorter interval between glucocorticoid withdrawal and the next relapse/exacerbation. CONCLUSION Our findings indicate that the level of FeNO is associated with the prognosis of ABPA. It can serve as an independent and valuable biomarker for evaluating the effectiveness of glucocorticoid treatment.
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Affiliation(s)
- Li-Sha Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China; Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Yi-Fan Wu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China; Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Hai-Wen Lu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China; Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Ling Wang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China; Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Jia-Yan Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China; Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Shu-Yi Gu
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Bei Mao
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Li Yu
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Jian-Xiong Li
- Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Dong Weng
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China; Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China; Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai, China.
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2
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Celik E, Kocacik Uygun D, Kaya MA, Gungoren MS, Keven A, Bingol A. Aspergillus-sensitized asthma in children. Pediatr Allergy Immunol 2024; 35:e14212. [PMID: 39099328 DOI: 10.1111/pai.14212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Asthma is the most common chronic respiratory disease in childhood. Aspergillus fumigatus sensitivity may be involved in the pathogenesis of asthma by leading to different clinical presentations. OBJECTIVE To investigate the demographic, clinical, laboratory, and radiological characteristics of A. fumigatus sensitivity in childhood asthma and identify associated risk factors and diagnostic parameters. METHODS A total of 259 children with asthma were included in the study, 7 (2.7%) with allergic bronchopulmonary aspergillosis (ABPA), 84 (32.4%) with A. fumigatus-sensitized asthma (Af-SA), and 168 (64.9%) with A. fumigatus-unsensitized asthma (Af-UA). RESULTS Aspergillus sensitivity was associated with early asthma onset and longer asthma duration. Total IgE level and asthma severity are highest in ABPA and higher in Af-SA. Absolute eosinophil count was higher, and FEV1 was lower in Af-SA and ABPA. Aspergillus fumigatus was associated with greater odds of being male (odds ratio [OR], 2.45), having atopic dermatitis (OR, 3.159), Alternaria sensitivity (OR, 10.37), and longer asthma duration (OR, 1.266). The best cut-off values for detecting A. fumigatus positivity were 363.5 IU/mL for total IgE and 455 cells/μL for absolute eosinophil count. In Af-SA compared to Af-UA, centrilobular nodules and peribronchial thickening were more common, and the bronchoarterial ratio was higher. CONCLUSIONS Aspergillus sensitivity is a strong allergic stimulus in asthma, leading to laboratory, structural, clinical, and functional consequences. Af-SA is a distinct asthma endotype independent of ABPA that is characterized by increased risk of severe clinical presentations and impaired lung function.
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Affiliation(s)
- Enes Celik
- Department of Pediatric Allergy-Immunology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Dilara Kocacik Uygun
- Department of Pediatric Allergy-Immunology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Mehmet Akif Kaya
- Department of Pediatric Allergy-Immunology, Akdeniz University School of Medicine, Antalya, Turkey
| | | | - Ayse Keven
- Department of Radiology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Aysen Bingol
- Department of Pediatric Allergy-Immunology, Akdeniz University School of Medicine, Antalya, Turkey
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Zhong S, Wu Z, Chen C, Xiao H, Wang Z. Near fatal asthma in a case of allergic bronchopulmonary aspergillosis (ABPA) treated with ECMO. J Asthma 2024; 61:889-893. [PMID: 38294679 DOI: 10.1080/02770903.2024.2307507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/16/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Fatal asthma is a rapidly progressing and highly fatal form of asthma. Mechanical ventilation, although necessary for respiratory support, can exacerbate the condition and lead to ventilator-associated lung injury. ECMO therapy is crucial in allowing the lungs to rest and recover, as it provides extracorporeal membrane oxygenation. CASE PRESENTATION A 40-year-old man presented with dyspnea following a mountain climb, which rapidly worsened, leading to respiratory failure and loss of consciousness. Despite drug therapy and mechanical ventilation, arterial blood gas analysis showed persistent hypercapnia. After 3 days of ECMO support, the patient was successfully extubated and underwent treatment for Aspergillus infection. Chest CT returned to normal after 3 months of anti-aspergillus therapy. CONCLUSION When drug therapy and mechanical ventilation fail to improve respiratory failure in fatal asthma, prompt initiation of ECMO support is essential to create opportunities for subsequent etiological treatment.
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Affiliation(s)
- Shili Zhong
- Department of Intensive Care Medicine, Army Medical Center of PLA, Chongqing, China
| | - Zhengbin Wu
- Department of Intensive Care Medicine, Army Medical Center of PLA, Chongqing, China
| | - Chunyan Chen
- Department of Intensive Care Medicine, Army Medical Center of PLA, Chongqing, China
| | - Hong Xiao
- Department of Intensive Care Medicine, Army Medical Center of PLA, Chongqing, China
| | - Zhen Wang
- Department of Intensive Care Medicine, Army Medical Center of PLA, Chongqing, China
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4
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Jaramillo C, Ferguson E, Odisio E, Ocazionez D. High-density pulmonary lesions: Review in chest imaging. Curr Probl Diagn Radiol 2024:S0363-0188(24)00117-8. [PMID: 39019711 DOI: 10.1067/j.cpradiol.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 07/08/2024] [Indexed: 07/19/2024]
Abstract
High-density pulmonary lesions are frequently seen in chest imaging, and it is important to identify their different causes. Radiologists must be able to distinguish between common and rare conditions in order to provide the best diagnosis and treatment. This article provides an overview of the various causes and imaging features of high-density lesions in the lungs. The lesions are classified into various categories, such as pulmonary nodules, inflammatory conditions, deposition diseases, contrast-related lesions, and thoracic devices. A clear understanding of these categories can help radiologists accurately diagnose and manage high-density pulmonary lesions encountered in practice.
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Affiliation(s)
- Catalina Jaramillo
- University of Texas Health Science Center at Houston, Department of Diagnostic & Interventional Imaging, 7000 Fannin St, Houston, TX, 77030.
| | - Emma Ferguson
- University of Texas Health Science Center at Houston, Department of Diagnostic & Interventional Imaging, 7000 Fannin St, Houston, TX, 77030
| | - Erika Odisio
- University of Texas Health Science Center at Houston, Department of Diagnostic & Interventional Imaging, 7000 Fannin St, Houston, TX, 77030
| | - Daniel Ocazionez
- University of Texas Health Science Center at Houston, Department of Diagnostic & Interventional Imaging, 7000 Fannin St, Houston, TX, 77030
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Sravanthi K, Jadhav D, Tambolkar S, Meshram SB, Patil MG, Mane S. A Case Report of Central Bronchiectasis in a Poorly Controlled Asthmatic Adolescent With Allergic Bronchopulmonary Aspergillosis and Secondary Spontaneous Pneumothorax. Cureus 2024; 16:e64792. [PMID: 39156318 PMCID: PMC11329887 DOI: 10.7759/cureus.64792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Accepted: 07/17/2024] [Indexed: 08/20/2024] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a multifaceted immune hypersensitivity reaction occurring in the lungs and bronchi, triggered by exposure and colonization of Aspergillus species, commonly Aspergillus fumigatus (A. fumigatus). It typically affects individuals who are immunocompetent but predisposed, such as those with bronchial asthma and cystic fibrosis. Diagnosis involves various methods including chest radiography, computed tomography, identification of eosinophilia, elevated serum IgE (immunoglobulin E) levels, and immunological tests for Aspergillus antigen. Left undiagnosed and untreated, ABPA can advance to bronchiectasis and/or pulmonary fibrosis, leading to significant morbidity and mortality.
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Affiliation(s)
- Kasireddy Sravanthi
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, IND
| | - Devika Jadhav
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, IND
| | - Sampada Tambolkar
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, IND
| | - Shailesh B Meshram
- Respiratory Medicine, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, IND
| | - Manojkumar G Patil
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, IND
| | - Shailaja Mane
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, IND
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Aigbirior J, Almaghrabi A, Lafi M, Mansur AH. The role of radiological imaging in the management of severe and difficult-to-treat asthma. Breathe (Sheff) 2024; 20:240033. [PMID: 39015661 PMCID: PMC11249838 DOI: 10.1183/20734735.0033-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/12/2024] [Indexed: 07/18/2024] Open
Abstract
Radiological imaging has proven to be a useful tool in the assessment of asthma, its comorbidities and potential complications. Characteristic chest radiograph and computed tomography scan findings can be seen in asthma and in other conditions that can coexist with or be misdiagnosed as asthma, including chronic rhinosinusitis, inducible laryngeal obstruction, excessive dynamic airway collapse, tracheobronchomalacia, concomitant COPD, bronchiectasis, allergic bronchopulmonary aspergillosis, eosinophilic granulomatosis with polyangiitis, and eosinophilic pneumonia. The identification of the characteristic radiological findings of these conditions is often essential in making the correct diagnosis and provision of appropriate management and treatment. Furthermore, radiological imaging modalities can be used to monitor response to therapy.
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Affiliation(s)
- Joshua Aigbirior
- Department of Respiratory Medicine, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Amer Almaghrabi
- Department of Respiratory Medicine, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Monder Lafi
- Medical School, Lancaster University, Lancaster, UK
| | - Adel H. Mansur
- Department of Respiratory Medicine, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Godet C, Brun AL, Couturaud F, Laurent F, Frat JP, Marchand-Adam S, Gagnadoux F, Blanchard E, Taillé C, Philippe B, Hirschi S, Andréjak C, Bourdin A, Chenivesse C, Dominique S, Mangiapan G, Murris-Espin M, Rivière F, Garcia G, Blanc FX, Goupil F, Bergeron A, Flament T, Priou P, Mal H, de Keizer J, Ragot S, Cadranel J. CT Imaging Assessment of Response to Treatment in Allergic Bronchopulmonary Aspergillosis in Adults With Bronchial Asthma. Chest 2024; 165:1307-1318. [PMID: 38387646 DOI: 10.1016/j.chest.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/10/2024] [Accepted: 02/17/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND One of the major challenges in managing allergic bronchopulmonary aspergillosis remains consistent and reproducible assessment of response to treatment. RESEARCH QUESTION What are the most relevant changes in CT scan parameters over time for assessing response to treatment? STUDY DESIGN AND METHODS In this ancillary study of a randomized clinical trial (NebuLamB), patients with asthma with available CT scan and without exacerbation during a 4-month allergic bronchopulmonary aspergillosis exacerbation treatment period (corticosteroids and itraconazole) were included. Changed CT scan parameters were assessed by systematic analyses of CT scan findings at initiation and end of treatment. CT scans were assessed by two radiologists anonymized to the clinical data. Radiologic parameters were determined by selecting those showing significant changes over time. Improvement of at least one, without worsening of the others, defined the radiologic response. Agreement between radiologic changes and clinical and immunologic responses was likewise investigated. RESULTS Among the 139 originally randomized patients, 132 were included. We identified five CT scan parameters showing significant changes at end of treatment: mucoid impaction extent, mucoid impaction density, centrilobular micronodules, consolidation/ground-glass opacities, and bronchial wall thickening (P < .05). These changes were only weakly associated with one another, except for mucoid impaction extent and density. No agreement was observed between clinical, immunologic, and radiologic responses, assessed as an overall response, or considering each of the parameters (Cohen κ, -0.01 to 0.24). INTERPRETATION Changes in extent and density of mucoid impaction, centrilobular micronodules, consolidation/ground-glass opacities, and thickening of the bronchial walls were found to be the most relevant CT scan parameters to assess radiologic response to treatment. A clinical, immunologic, and radiologic multidimensional approach should be adopted to assess outcomes, probably with a composite definition of response to treatment. TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT02273661; URL: www. CLINICALTRIALS gov).
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Affiliation(s)
- Cendrine Godet
- Service de Pneumologie B et Transplantation pulmonaire, Université Paris Cité, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France.
| | | | - Francis Couturaud
- Université Brest, INSERM U1304-GETBO, CHU Brest, Département de Médecine Interne et Pneumologie, CIC INSERM 1412, CHU Brest, FCRIN INNOVTE, France; Département de Médecine Interne et Pneumologie, CHU Brest, France
| | - François Laurent
- Université Bordeaux, INSERM, CRCTB, U 1045, F-33000 Bordeaux, France
| | - Jean-Pierre Frat
- Médecine Intensive Réanimation, CHU Poitiers, Poitiers, France; Université Poitiers, INSERM, CIC 1402, IS-ALIVE, CHU Poitiers, Poitiers, France
| | - Sylvain Marchand-Adam
- Université François Rabelais, Tours, INSERM 1100, Tours, France; Service de pneumologie et explorations fonctionnelles respiratoires, CHRU de Tours, Tours, France
| | - Frédéric Gagnadoux
- Service de Pneumologie et Allergologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Elodie Blanchard
- Service de Pneumologie, CHU Bordeaux site Haut Lévêque Pessac, France
| | - Camille Taillé
- Service de Pneumologie et Centre de Référence constitutif des Maladies Pulmonaires Rares, AP-HP Nord-Université Paris Cité, Hôpital Bichat, INSERM, UMR 1152, Paris, France
| | | | - Sandrine Hirschi
- Service de Pneumologie, Centre de Compétence des Maladies Pulmonaires Rares, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Claire Andréjak
- Service de Pneumologie, CHU Amiens Picardie, Amiens, France; Université Picardie Jules Verne, UR 4294, CHU Amiens Picardie, Amiens, France
| | - Arnaud Bourdin
- Université Montpellier, INSERM, CNRS, CHU Montpellier, PhyMed Exp, Montpellier, France
| | - Cécile Chenivesse
- Université Lille, CNRS, INSERM, CHU Lille, U1019 - UMR9017 - CIIL - Center for Infection and Immunity of Lille, F-5900 Lille, France; CRISALIS, F-CRIN Network, INSERM US015, Toulouse, France
| | | | | | - Marlène Murris-Espin
- Service de Pneumologie, CRCM adulte et Transplantation pulmonaire, Clinique des Voies Respiratoires, CHU de Toulouse, Hôpital Larrey, Toulouse, France
| | - Frédéric Rivière
- Service de Pneumologie, Centre Hospitalier Universitaire Côte de Nacre, Caen, France
| | - Gilles Garcia
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR-S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique - Hôpitaux de Paris, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - François-Xavier Blanc
- Nantes Université, CHU Nantes, INSERM, Service de Pneumologie, CIC 1413, l'institut du thorax, Nantes, France
| | | | - Anne Bergeron
- Division of Pulmonology, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Flament
- Service de pneumologie et explorations fonctionnelles respiratoires, CHRU de Tours, Tours, France
| | - Pascaline Priou
- Service de Pneumologie et Allergologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Hervé Mal
- Service de Pneumologie B et Transplantation pulmonaire, Université Paris Cité, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Joe de Keizer
- Université Poitiers, INSERM, CIC-1402, Biostatistics, Poitiers, France, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers, France
| | - Stéphanie Ragot
- Université Poitiers, INSERM, CIC-1402, Biostatistics, Poitiers, France, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers, France
| | - Jacques Cadranel
- Service de Pneumologie et Oncologie Thoracique, Centre constitutif Maladies pulmonaires rares, Université Paris Sorbonne, Assistance Publique - Hôpitaux de Paris, Hôpital Tenon, Paris, France
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Marra AM, Curci P, Franco G, Pittalis G, Tugnoli E, Cavasin D, Cristiano A, Bini F. Coexistence of Eosinophilic Granulomatosis With Polyangiitis and Allergic Bronchopulmonary Aspergillosis: A Fascinating Relationship. Cureus 2024; 16:e57917. [PMID: 38601813 PMCID: PMC11004847 DOI: 10.7759/cureus.57917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 04/12/2024] Open
Abstract
Elevated eosinophil counts are associated with various diseases, including eosinophilic granulomatosis with polyangiitis (EGPA) and allergic bronchopulmonary aspergillosis (ABPA). EGPA is a rare small-vessel vasculitis characterized by asthma, eosinophilia, fleeting pulmonary infiltrates, and systemic manifestations. ABPA, initiated by immune reactions against Aspergillus fumigatus in the airways, presents with poorly controlled asthma, wheezing, hemoptysis, productive cough, and systemic symptoms, which result in characteristic central bronchiectasis. Fleeting pulmonary opacities are common radiologic findings. We present a case of ABPA in a patient with a prior EGPA diagnosis under treatment with mepolizumab 300 mg monthly and review eight similar cases from the literature. In these cases, EGPA and ABPA diagnoses preceded each other or were concurrent. Treatment of the latter improved control of both diseases. IL-5 is pivotal in EGPA pathogenesis, and mepolizumab, targeting IL-5, has been effective in EGPA treatment. Our patient received mepolizumab for EGPA and continued it post-ABPA diagnosis, showing favorable outcomes. This suggests mepolizumab as a therapeutic link between EGPA and ABPA. Mepolizumab therapy holds promise for managing both EGPA and ABPA. Double-blind placebo-controlled studies are warranted to establish its efficacy and safety for ABPA, emphasizing the need for further research in this area.
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Affiliation(s)
| | - Pietro Curci
- Respiratory Unit, School of Medicine and Surgery, Università degli Studi di Milano Bicocca, Fondazione IRCCS San Gerardo dei Tintori, Monza, ITA
| | - Giovanni Franco
- Respiratory Unit, School of Medicine and Surgery, Università degli Studi di Milano Bicocca, Fondazione IRCCS San Gerardo dei Tintori, Monza, ITA
| | - Giulia Pittalis
- Pneumology Unit, Azienda Socio Sanitaria Territoriale (ASST) Rhodense, Milan, ITA
| | - Erica Tugnoli
- Respiratory Unit, School of Medicine and Surgery, Università degli Studi di Milano Bicocca, Fondazione IRCCS San Gerardo dei Tintori, Monza, ITA
| | - Davide Cavasin
- Respiratory Unit, School of Medicine and Surgery, Università degli Studi di Milano Bicocca, Fondazione IRCCS San Gerardo dei Tintori, Monza, ITA
| | - Andrea Cristiano
- Pneumology Unit, Azienda Socio Sanitaria Territoriale (ASST) Rhodense, Milan, ITA
| | - Francesco Bini
- Pneumology Unit, Azienda Socio Sanitaria Territoriale (ASST) Rhodense, Milan, ITA
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9
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Maule M, Vitte J, Ambrosani F, Caminati M. Epidemiology of the relationship between allergic bronchopulmonary aspergillosis and asthma. Curr Opin Allergy Clin Immunol 2024; 24:102-108. [PMID: 38295145 DOI: 10.1097/aci.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
PURPOSE OF REVIEW Allergic bronchopulmonary aspergillosis (ABPA) can complicate the natural history of asthmatic patients, especially the more severe ones, worsening disease control and increasing the need for therapies, steroids in particular, and medical care. The aim of the present review is to summarize the latest epidemiological data related to the relationship between asthma and ABPA and to offer a summary of the most recent strategies that could potentially facilitate in the identification of ABPA in asthmatic patients. RECENT FINDINGS In the last years, great efforts have been made by researchers worldwide to provide reliable epidemiological data on fungal sensitization and ABPA, especially in severe asthma patients both in adult and pediatric population. Data differ depending on the geographical area and population studied, but pooled data show a concerning 11% of severe asthma patients having ABPA and one out of four asthmatic patients being sensitized to fungi, Aspergillus fumigatus in particular. SUMMARY Reliable epidemiological data and advances in the diagnostic procedures can facilitate the detection of ABPA among asthmatic patients, improving the management of a still under-recognized and challenging condition.
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Affiliation(s)
- Matteo Maule
- Asthma Center and Allergy Unit, Center for Hyper-eosinophilic dysimmune conditions, Integrated University Hospital of Verona
- Department of Medicine, University of Verona, Verona, Italy
| | - Joana Vitte
- University Hospital of Reims, Laboratory of Immunology
- INSERM UMR-S 1250 P3CELL, University of Reims, Reims, France
| | | | - Marco Caminati
- Asthma Center and Allergy Unit, Center for Hyper-eosinophilic dysimmune conditions, Integrated University Hospital of Verona
- Department of Medicine, University of Verona, Verona, Italy
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10
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Agarwal R, Sehgal IS, Muthu V, Denning DW, Chakrabarti A, Soundappan K, Garg M, Rudramurthy SM, Dhooria S, Armstrong-James D, Asano K, Gangneux JP, Chotirmall SH, Salzer HJF, Chalmers JD, Godet C, Joest M, Page I, Nair P, Arjun P, Dhar R, Jat KR, Joe G, Krishnaswamy UM, Mathew JL, Maturu VN, Mohan A, Nath A, Patel D, Savio J, Saxena P, Soman R, Thangakunam B, Baxter CG, Bongomin F, Calhoun WJ, Cornely OA, Douglass JA, Kosmidis C, Meis JF, Moss R, Pasqualotto AC, Seidel D, Sprute R, Prasad KT, Aggarwal AN. Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses. Eur Respir J 2024; 63:2400061. [PMID: 38423624 PMCID: PMC10991853 DOI: 10.1183/13993003.00061-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The International Society for Human and Animal Mycology (ISHAM) working group proposed recommendations for managing allergic bronchopulmonary aspergillosis (ABPA) a decade ago. There is a need to update these recommendations due to advances in diagnostics and therapeutics. METHODS An international expert group was convened to develop guidelines for managing ABPA (caused by Aspergillus spp.) and allergic bronchopulmonary mycosis (ABPM; caused by fungi other than Aspergillus spp.) in adults and children using a modified Delphi method (two online rounds and one in-person meeting). We defined consensus as ≥70% agreement or disagreement. The terms "recommend" and "suggest" are used when the consensus was ≥70% and <70%, respectively. RESULTS We recommend screening for A. fumigatus sensitisation using fungus-specific IgE in all newly diagnosed asthmatic adults at tertiary care but only difficult-to-treat asthmatic children. We recommend diagnosing ABPA in those with predisposing conditions or compatible clinico-radiological presentation, with a mandatory demonstration of fungal sensitisation and serum total IgE ≥500 IU·mL-1 and two of the following: fungal-specific IgG, peripheral blood eosinophilia or suggestive imaging. ABPM is considered in those with an ABPA-like presentation but normal A. fumigatus-IgE. Additionally, diagnosing ABPM requires repeated growth of the causative fungus from sputum. We do not routinely recommend treating asymptomatic ABPA patients. We recommend oral prednisolone or itraconazole monotherapy for treating acute ABPA (newly diagnosed or exacerbation), with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations. We have devised an objective multidimensional criterion to assess treatment response. CONCLUSION We have framed consensus guidelines for diagnosing, classifying and treating ABPA/M for patient care and research.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Kathirvel Soundappan
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Darius Armstrong-James
- Faculty of Medicine, Department of Infectious Disease, Imperial College London, London, UK
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Jean-Pierre Gangneux
- Université Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail), UMR_S 1085, Rennes, France
- CHU Rennes, Laboratoire de Parasitologie-Mycologie, ECMM Excellence Center in Medical Mycology, Rennes, France
- National Reference Center on Mycoses and Antifungals (CNRMA LA-Asp C), Rennes, France
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University (NTU) and Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Helmut J F Salzer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine-Pneumology, Kepler University Hospital and Medical Faculty, Johannes Kepler University, Linz, Austria
| | | | - Cendrine Godet
- Université Paris Sorbonne, AP-HP, Hôpital Tenon, Service de Pneumologie et Oncologie Thoracique, Centre Constitutif Maladies Pulmonaires Rares Paris, Paris, France
| | | | - Iain Page
- NHS Lothian, Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Parameswaran Nair
- McMaster University, McGill University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - P Arjun
- KIMS Hospital, Trivandrum, India
| | - Raja Dhar
- Department of Pulmonology, CK Birla Hospitals, Kolkata, India
| | - Kana Ram Jat
- Division of Pediatric Pulmonology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Joseph L Mathew
- Pediatric Pulmonology Division, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Nath
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute, Lucknow, India
| | - Dharmesh Patel
- City Clinic and Bhailal Amin General Hospital, Vadodara, India
| | - Jayanthi Savio
- Department of Microbiology, St John's Medical College and Hospital, Bengaluru, India
| | - Puneet Saxena
- Pulmonary and Critical Care Medicine, Army Hospital (R&R), New Delhi, India
| | - Rajeev Soman
- Department of Infectious Diseases, Jupiter Hospital, Pune, India
| | | | - Caroline G Baxter
- Department of Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - William J Calhoun
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Oliver A Cornely
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
| | - Jo A Douglass
- University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
| | - Chris Kosmidis
- Division of Evolution, Infection and Genomics, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jacques F Meis
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
- Center of Expertise in Mycology Radboudumc/CWZ Nijmegen, Nijmegen, The Netherlands
| | - Richard Moss
- Center of Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Alessandro C Pasqualotto
- Molecular Biology Laboratory, Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Danila Seidel
- Department of Internal Medicine, University Hospital, Cologne, Germany
| | - Rosanne Sprute
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kanaujia R, Arora A, Chakrabarti A, Rudramurthy SM, Agarwal R. Polymorphisms in Innate and Adaptive Immune Genes in Subjects with Allergic Bronchopulmonary Aspergillosis Complicating Asthma. Mycopathologia 2024; 189:23. [PMID: 38407762 DOI: 10.1007/s11046-024-00834-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/29/2024] [Indexed: 02/27/2024]
Abstract
Innate and adaptive immunity play a crucial role in allergic bronchopulmonary aspergillosis (ABPA) pathogenesis. We performed next-generation sequencing using the Illumina TruSight One panel (4,811 human disease-associated genes, at least 20 × coverage) and selected 22 known immune genes (toll-like receptors (TLRs), C-type lectin, interleukin-4 receptor, and others). We included ABPA (n = 18), asthma without ABPA (n = 12), and healthy controls (n = 8). We analyzed 3011 SNPs from 22 genes and identified 145 SNPs (13 genes) that were present only in the disease groups and absent in controls. The SNP frequency overall was significantly higher in ABPA than in asthmatics (89/145 [61.4%] vs. 56/145 [38.6%], p = 0.0001). The SNP frequency in the TLR10 gene was also significantly higher in ABPA than in asthma (p = 0.017). Association analysis further revealed three genes having significant associations. Of these, NOS3 and HLA-DQB1 are associated with antimicrobial activity and adaptive immunity. More extensive studies are required to confirm our findings.
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Affiliation(s)
- Rimjhim Kanaujia
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, India
| | - Amit Arora
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, India.
| | | | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, India.
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12
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Agarwal R, Muthu V, Sehgal IS. Clinical Manifestation and Treatment of Allergic Bronchopulmonary Aspergillosis. Semin Respir Crit Care Med 2024; 45:114-127. [PMID: 38154470 DOI: 10.1055/s-0043-1776912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction to airway colonization by Aspergillus fumigatus in patients with asthma and cystic fibrosis. The pathophysiology of ABPA involves a complex interplay between the fungus and the host immune response, which causes persistent inflammation and tissue damage. Patients present with chronic cough, wheezing, and dyspnea due to uncontrolled asthma. Characteristic symptoms include the expectoration of brownish mucus plugs. Radiographic findings often reveal fleeting pulmonary infiltrates, bronchiectasis, and mucus impaction. However, the definitive diagnosis of ABPA requires a combination of clinical, radiological, and immunological findings. The management of ABPA aims to reduce symptoms, prevent disease progression, and minimize the future risk of exacerbations. The treatment approach involves systemic glucocorticoids or antifungal agents to suppress the inflammatory response or fungal growth and prevent exacerbations. Biological agents may be used in patients with severe disease or glucocorticoid dependence. This review provides an overview of the clinical manifestations and current treatment options for ABPA.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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13
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Schwarz C, Eschenhagen PN, Mainz JG, Schmidergall T, Schuette H, Romanowska E. Pulmonary Aspergillosis in People with Cystic Fibrosis. Semin Respir Crit Care Med 2024; 45:128-140. [PMID: 38286138 DOI: 10.1055/s-0043-1777267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
In the last decade, fungal respiratory diseases have been increasingly investigated for their impact on the clinical course of people with cystic fibrosis (CF), with a particular focus on infections caused by Aspergillus spp. The most common organisms from this genus detected from respiratory cultures are Aspergillus fumigatus and Aspergillus terreus, followed by Aspergillus flavus, Aspergillus niger, and Aspergillus nidulans. These species have been identified to be both chronic colonizers and sources of active infection and may negatively impact lung function in people with CF. This review article discusses definitions of aspergillosis, challenges in clinical practice, and current literature available for laboratory findings, clinical diagnosis, and treatment options for pulmonary diseases caused by Aspergillus spp. in people with CF.
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Affiliation(s)
- C Schwarz
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
| | - P N Eschenhagen
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
| | - J G Mainz
- Department of Paediatric Pneumology, Allergology, Cystic Fibrosis Center, Klinikum Westbrandenburg, Brandenburg a. d. Havel, Germany
- University Hospital of the Brandenburg Medical School, Brandenburg a. d. Havel, Germany
| | - T Schmidergall
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
| | - H Schuette
- Pneumology and Respiratory Medicine, Ernst von Bergmann Klinikum, Potsdam, Germany
| | - E Romanowska
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
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14
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Hattori S, Oguma T, Ishiguro T, Suzuki J, Fukunaga K, Shimoda T, Kimura H, Obase Y, Okada N, Tanaka J, Kitahara A, Tomomatsu K, Shiraishi Y, Asano K. High attenuation mucus in bronchi with allergic bronchopulmonary mycosis. Mycoses 2024; 67:e13705. [PMID: 38369597 DOI: 10.1111/myc.13705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND High-attenuation mucus (HAM) is a specific manifestation of allergic bronchopulmonary mycosis (ABPM) on chest computed tomography (CT). OBJECTIVES To compare the diagnostic accuracy of the two definitions of HAM and to clarify the clinical and radiographic characteristics of HAM-positive and HAM-negative ABPM. METHODS CT images at the diagnosis of ABPM using Asano's criteria were retrospectively analysed. In Study #1, radiographic data obtained using the same CT apparatus in a single institute were analysed to determine the agreement between the two definitions of HAM: a mucus plug that is visually denser than the paraspinal muscles or that with a radiodensity ≥70 Hounsfield units. In Study #2, HAM was diagnosed by comparison with the paraspinal muscles in patients with ABPM reporting to 14 medical institutes in Japan. RESULTS In Study #1, 93 mucus plugs from 26 patients were analysed. A substantial agreement for HAM diagnosis was observed between the two methods, with a κ coefficient of 0.72. In Study #2, 60 cases of ABPM were analysed; mucus plugs were present in all cases and HAM was diagnosed in 45 (75%) cases. The median A. fumigatus-specific IgE titre was significantly lower in HAM-positive patients than in HAM-negative patients (2.5 vs. 24.3 UA /mL, p = .004). Nodular shadows were observed more frequently in the airways distal to HAM than in those distal to non-HAM mucus plugs (59% vs. 32%, p < .001). CONCLUSION In conclusion, agreement between the two methods to diagnose HAM was substantial. HAM was associated with some immunological and radiographic characteristics, including lower levels of sensitization to A. fumigatus and the presence of distal airway lesions.
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Affiliation(s)
- Shigeaki Hattori
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Tsuyoshi Oguma
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Takashi Ishiguro
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Saitama, Japan
| | - Junko Suzuki
- Department of Allergy, Clinical Research Center, National Hospital Organization Fukuoka Hospital, Fukuoka, Japan
| | - Koichi Fukunaga
- Department of Respiratory Medicine, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Terufumi Shimoda
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hirokazu Kimura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Naoki Okada
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Jun Tanaka
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Asako Kitahara
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Katsuyoshi Tomomatsu
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Yoshiki Shiraishi
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
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Carriera L, Fantò M, Martini A, D’Abramo A, Puzio G, Scaramozzino MU, Coppola A. Combination of Biological Therapy in Severe Asthma: Where We Are? J Pers Med 2023; 13:1594. [PMID: 38003909 PMCID: PMC10672189 DOI: 10.3390/jpm13111594] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Biological drugs have revolutionized the management of severe asthma. However, a variable number of patients remain uncontrolled or only partially controlled even after the appropriate administration of a biologic agent. The combination of two biologics may target different inflammatory pathways, and it has been used in patients suffering from uncontrolled severe asthma with evidence of both allergic and eosinophilic phenotypes or severe asthma and type2 comorbidities. Combination therapy has also been used to handle anti-IL4/13R induced hypereosinophilia. There is insufficient data on combining biologics for the treatment of severe uncontrolled asthma and type 2 comorbidities, also because of the high cost, and currently no guideline recommends dual biologic therapy. A systematic search was performed using the Medline and Scopus databases. Published data on concurrent administration of two biological drugs in severe, uncontrolled asthma patients has been reported in 28 real-world studies and 1 clinical trial. Data extraction was followed by a descriptive and narrative synthesis of the findings. Future studies should be conducted to further assess the safety, efficacy, and cost-effectiveness of this therapeutic strategy.
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Affiliation(s)
- Lorenzo Carriera
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Marta Fantò
- UOSD Allergologia e Immunologia Clinica, A.O. San Donato, USL Toscana Sud Est, 52100 Arezzo, Italy;
| | - Alessia Martini
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Alice D’Abramo
- UOC Pneumologia, Ospedale San Filippo Neri-ASL Roma 1, 00135 Rome, Italy; (A.D.); (G.P.); (A.C.)
| | - Genesio Puzio
- UOC Pneumologia, Ospedale San Filippo Neri-ASL Roma 1, 00135 Rome, Italy; (A.D.); (G.P.); (A.C.)
| | | | - Angelo Coppola
- UOC Pneumologia, Ospedale San Filippo Neri-ASL Roma 1, 00135 Rome, Italy; (A.D.); (G.P.); (A.C.)
- UniCamillus, Saint Camillus International University of Health Sciences, 00131 Rome, Italy
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Madhavan V, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Aggarwal AN, Agarwal R. Malnutrition in Allergic Bronchopulmonary Aspergillosis complicating asthma. Lung India 2023; 40:563-566. [PMID: 37961971 PMCID: PMC10723196 DOI: 10.4103/lungindia.lungindia_360_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/21/2023] [Accepted: 09/10/2023] [Indexed: 11/15/2023] Open
Affiliation(s)
- Venkateshan Madhavan
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India E-mail:
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India E-mail:
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India E-mail:
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India E-mail:
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India E-mail:
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India E-mail:
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17
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Agarwal R, Sehgal IS, Muthu V, Dhooria S, Prasad KT, Aggarwal AN, Garg M, Rudramurthy SM, Chakrabarti A. Long-term follow-up of allergic bronchopulmonary aspergillosis treated with glucocorticoids: A study of 182 subjects. Mycoses 2023; 66:953-959. [PMID: 37555291 DOI: 10.1111/myc.13640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/28/2023] [Accepted: 07/28/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The long-term outcomes of allergic bronchopulmonary aspergillosis (ABPA) are poorly characterised. METHODS We retrospectively included treatment-naïve subjects of acute stage ABPA-complicating asthma from three randomised trials. All the subjects received oral prednisolone for 4 months and were monitored every 6 weeks for 6 months and then every 6 months. Our primary objective was to estimate the incidence rate and the frequency of subjects experiencing ABPA exacerbation. The key secondary objectives were to evaluate the factors predicting ABPA exacerbation and the changes in serum total IgE seen during treatment. RESULTS We included 182 subjects. Eighty-one (44.5%) patients experienced 120 exacerbations during 512 patient-years of follow-up. The incidence rate of ABPA exacerbations was 234/1000 patient-years. Most (73/81, 90.1%) subjects experienced ABPA exacerbation within three years of stopping therapy. On multivariate logistic regression analysis, peripheral blood eosinophil count ≥1000 cells/μL (adjusted odds ratio [aOR] 2.43; 95% confidence interval (CI), 1.26-4.67), the extent of bronchiectasis (aOR 1.10; 95% CI, 1.03-1.18), age (aOR 0.97; 95% CI, 0.94-0.99), and female sex (aOR 2.16; 95% CI, 1.10-4.24) independently predicted ABPA exacerbation after adjusting for serum total IgE and high-attenuation mucus. The best cut-off for serum total IgE after 6 weeks for identifying treatment response and ABPA exacerbations was a 20% decline and a 50% increase, respectively. CONCLUSIONS ABPA exacerbations were common within 3 years of stopping treatment. Age, female sex, peripheral blood eosinophilia and the extent of bronchiectasis predicted ABPA exacerbations. The optimal serum total IgE cut-off for defining ABPA response and exacerbations is a 20% decline and a 50% increase, respectively.
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Affiliation(s)
- Ritesh Agarwal
- 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
| | - Valliappan Muthu
- 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
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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18
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Liu A, Chen W, Wei Y, Liang J, Liao S, Chen Y, Li Y, Wang X, Chen W, Qiu Y, Li Z, Ye F. Comparison of diagnostic efficiency of detecting IgG and IgE with immunoassay method in diagnosing ABPA: a meta-analysis. BMC Pulm Med 2023; 23:374. [PMID: 37798745 PMCID: PMC10557217 DOI: 10.1186/s12890-023-02620-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Hitherto, the bulk of diagnostic criteria regards Aspergillus-specific immunoglobulin E as a key item, and regard IgG as an auxiliary method in diagnose. Nevertheless, there is no conclusive study in summarize the performance of IgG and IgE diagnosing ABPA. METHODS We conducted a systematic review to identify studies report results of IgE and IgG detection in diagnosing ABPA. QUADAS-2 tool was used to evaluate included studies, and we applied the HSROC model to calculate the pooled sensitivity and specificity. Deeks' funnel was derived to evaluated the public bias of included studies, and Cochrane Q test and I2 statistic were used to test the heterogeneity. RESULTS Eleven studies were included in this study (1127 subjects and 215 for IgE and IgG). Deeks's test for IgE and IgG were 0.10 and 0.19. The pooled sensitivity and specificity for IgE were 0.83 (95%CI: 0.77, 0.90) and 0.89 (0.83, 0.94), and for IgG were 0.93 (0.87, 0.97) and 0.73 (0.62,0.82), with P value < 0.001. The PLR and NLR for IgE were 7.80 (5.03,12.10) and 0.19 (0.13,0.27), while for IgG were 3.45 (2.40,4.96) and 0.09 (0.05,0.17). The combined diagnostic odds ratio and diagnostic score were 41.49 (26.74,64.36) and3.73 (3.29,4.16) for IgE, respectively, and were 38.42 (19.23,76.79) and 3.65 (2.96,4.34) for IgG. CONCLUSION The sensitivity for IgG diagnosing ABPA is higher than IgE, while the specificity for IgE is higher. IgG might be able to play a more important role in filtering ABPA patients.
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Affiliation(s)
- Anlin Liu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
- Nanshan School of Guangzhou Medical University, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Xi Road, Guangzhou, 510120, Guangdong, China
| | - Wushu Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
- Nanshan School of Guangzhou Medical University, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Xi Road, Guangzhou, 510120, Guangdong, China
| | - Yining Wei
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
- Nanshan School of Guangzhou Medical University, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Xi Road, Guangzhou, 510120, Guangdong, China
| | - Jinkai Liang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
- Nanshan School of Guangzhou Medical University, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Xi Road, Guangzhou, 510120, Guangdong, China
| | - Shuhong Liao
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
- Nanshan School of Guangzhou Medical University, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Xi Road, Guangzhou, 510120, Guangdong, China
| | - Yijun Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Yongming Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Xidong Wang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Weisi Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Ye Qiu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.
| | - Zhengtu Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.
| | - Feng Ye
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.
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Nakayama T, Miyata J, Inoue N, Ueki S. Allergic fungal rhinosinusitis: What we can learn from allergic bronchopulmonary mycosis. Allergol Int 2023; 72:521-529. [PMID: 37442743 DOI: 10.1016/j.alit.2023.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 06/03/2023] [Indexed: 07/15/2023] Open
Abstract
Allergic fungal rhinosinusitis (AFRS) and allergic bronchopulmonary mycosis (ABPM) are inflammatory disorders of the respiratory tract resulting from type 1 and 3 hypersensitivity reactions against fungi. The hallmark features of both diseases are eosinophil infiltration into the airway mucosa caused by localized type 2 inflammation and concomitant viscid secretions in the airways. Eosinophilic mucin-induced compression of adjacent anatomic structures leads to bone erosion and central bronchiectasis in the upper and lower respiratory tracts, respectively. Although these diseases share common features in their pathogenesis, they also exhibit notable differences. Epidemiologic findings are diverse, with AFRS typically presenting at a younger age, exhibiting less complicated bronchial asthma, and displaying lower total immunoglobulin E levels in laboratory findings compared with ABPM. Furthermore, despite their similar pathogenesis, the rarity of sinio-bronchial allergic mycosis in both AFRS and ABPM underscores the distinctions between these two diseases. This review aims to clarify the similarities and differences in the pathogenesis of AFRS and ABPM to determine what can be learned about AFRS from ABPM, where more is known.
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Affiliation(s)
- Tsuguhisa Nakayama
- Department of Otorhinolaryngology and Head & Neck Surgery, Dokkyo Medical University, Tochigi, Japan.
| | - Jun Miyata
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Natsuki Inoue
- Department of Otorhinolaryngology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Shigeharu Ueki
- Department of General Internal Medicine and Clinical Laboratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
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Agarwal R, Muthu V, Sehgal IS. Relationship between Aspergillus and asthma. Allergol Int 2023; 72:507-520. [PMID: 37633774 DOI: 10.1016/j.alit.2023.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/28/2023] Open
Abstract
Fungal sensitization is highly prevalent in severe asthma. The relationship between fungus and asthma, especially Aspergillus fumigatus, has been the subject of extensive research. The ubiquitous presence of A. fumigatus, its thermotolerant nature, the respirable size of its conidia, and its ability to produce potent allergens are pivotal in worsening asthma control. Due to the diverse clinical manifestations of fungal asthma and the lack of specific biomarkers, its diagnosis remains intricate. Diagnosing fungal asthma requires carefully assessing the patient's clinical history, immunological tests, and imaging. Depending on the severity, patients with fungal asthma require personalized treatment plans, including inhaled corticosteroids and bronchodilators, and antifungal therapy. This review provides a comprehensive overview of the association between Aspergillus and asthma by reviewing the relevant literature and highlighting key findings. We discuss the diagnosis of various entities included in fungal asthma. We also debate whether newer definitions, including allergic fungal airway disease, offer any additional advantages over the existing ones. Finally, we provide the current treatment options for the individual entities, including A. fumigatus-associated asthma, severe asthma with fungal sensitization, and allergic bronchopulmonary mycoses.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (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
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21
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Sehgal IS, Arora K, Cornely OA, Salzer HJF, Dhooria S, Prasad KT, Garg M, Rudramurthy SM, Muthu V, Aggarwal AN, Chakrabarti A, Agarwal R. Characterization of Treatment Response Outcomes in Chronic Pulmonary Aspergillosis: CPAnet Definitions Versus the Existing Criteria. Mycopathologia 2023; 188:721-730. [PMID: 37291204 DOI: 10.1007/s11046-023-00751-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND The chronic pulmonary aspergillosis network (CPAnet) has recently proposed definitions for treatment outcomes in CPA. However, these definitions need to be validated. Herein, we evaluate the agreement between the existing and the CPAnet definitions for response assessment. METHODS We enrolled consecutive treatment-naïve CPA subjects (between January 2021 and June 2021) who received six months of itraconazole therapy and followed them for an additional six months after treatment discontinuation. We retrospectively applied the CPAnet criteria and compared the agreement between the existing and the CPAnet criteria for response assessment (primary objective). We also assessed if adding weight loss (> 5% from baseline) as a component improved the performance of the CPAnet criteria. RESULTS We included 43 (mean age, 47.4 years) CPA subjects. The existing and the CPAnet criteria categorized 29 (67.4%) and 30 (69.8%) subjects as treatment success, respectively, at treatment completion. There was substantial (kappa = 0.73; p < 0.0001) agreement between the two definitions. However, both criteria did not identify eight subjects requiring treatment re-initiation within three months. There was an increment in the sensitivity of both criteria (by 36%) for identifying treatment failure after incorporating ≥ 5% weight loss as an element of worsening. CONCLUSION The CPAnet definitions correctly categorized treatment outcomes in most cases of CPA. The addition of weight change would further enhance the performance of the CPAnet treatment outcome definitions.
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Affiliation(s)
- Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Kajal Arora
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Oliver A Cornely
- Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Helmut J F Salzer
- Department of Internal Medicine 4 - Pneumology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Mandeep Garg
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | | | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India.
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Sakaida H, Takeuchi K. Allergic Fungal Otomastoiditis: A Case Report. Cureus 2023; 15:e45446. [PMID: 37727842 PMCID: PMC10506369 DOI: 10.7759/cureus.45446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 09/21/2023] Open
Abstract
Otomastoiditis caused by an allergic reaction to fungi in the middle ear is rare, with only four cases reported in the English literature. We report the case of a patient with allergic fungal otomastoiditis. A 28-year-old man presented with otalgia, hearing loss, and vertigo. Exploratory tympanotomy revealed mucin with a peanut butter-like consistency and containing eosinophils and Candida parapsilosis, but no evidence of direct tissue invasion by fungi. The patient was treated with a combination of surgery and medication. Subtotal petrosectomy was finally performed to remove the middle ear mucosa and separate the middle ear from the external environment. Short-term prednisolone and long-term fluconazole were administered without satisfactory therapeutic results. The inflammatory condition has improved but continues without complete remission. Allergic fungal otomastoiditis is an extremely rare condition that may share pathophysiological features with allergic fungal rhinosinusitis, so a thorough examination combining bacterial cultures, histopathological examination with fungal staining, and serum antigen-specific immunoglobulin E against multiple fungi is essential. Optimal treatment probably comprises appropriate surgery and long-term administration of systemic corticosteroids. Definitive diagnostic criteria and therapeutic strategies need to be established, based on the accumulation of similar cases.
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Affiliation(s)
- Hiroshi Sakaida
- Department of Otorhinolaryngology-Head and Neck Surgery, Mie University Graduate School of Medicine, Mie, JPN
| | - Kazuhiko Takeuchi
- Department of Otorhinolaryngology-Head and Neck Surgery, Mie University Graduate School of Medicine, Mie, JPN
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23
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Hetta HF, Ramadan YN, Al-Kadmy IMS, Ellah NHA, Shbibe L, Battah B. Nanotechnology-Based Strategies to Combat Multidrug-Resistant Candida auris Infections. Pathogens 2023; 12:1033. [PMID: 37623993 PMCID: PMC10458664 DOI: 10.3390/pathogens12081033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/02/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023] Open
Abstract
An emerging multidrug-resistant pathogenic yeast called Candida auris has a high potential to spread quickly among hospitalized patients and immunodeficient patients causing nosocomial outbreaks. It has the potential to cause pandemic outbreaks in about 45 nations with high mortality rates. Additionally, the fungus has become resistant to decontamination techniques and can survive for weeks in a hospital environment. Nanoparticles might be a good substitute to treat illnesses brought on by this newly discovered pathogen. Nanoparticles have become a trend and hot topic in recent years to combat this fatal fungus. This review gives a general insight into the epidemiology of C. auris and infection. It discusses the current conventional therapy and mechanism of resistance development. Furthermore, it focuses on nanoparticles, their different types, and up-to-date trials to evaluate the promising efficacy of nanoparticles with respect to C. auris.
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Affiliation(s)
- Helal F. Hetta
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut 71515, Egypt;
| | - Yasmin N. Ramadan
- Department of Microbiology and Immunology, Faculty of Pharmacy, Assiut University, Assiut 71515, Egypt;
| | - Israa M. S. Al-Kadmy
- Branch of Biotechnology, Department of Biology, College of Science, Mustansiriyah University, Baghdad P.O. Box 10244, Iraq;
| | - Noura H. Abd Ellah
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut 71515, Egypt;
- Department of Pharmaceutics, Faculty of Pharmacy, Badr University in Assiut, Naser City, Assiut 2014101, Egypt
| | - Lama Shbibe
- Faculty of Science, Damascus University, Damascus 97009, Syria;
| | - Basem Battah
- Department of Biochemistry and Microbiology, Faculty of Pharmacy, Syrian Private University (SPU), Daraa International Highway, Damascus 36822, Syria
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Chiam JTW, Chua JW. Now You See It, Now You Don't - Allergic Bronchopulmonary Aspergillosis Presenting as a Vanishing Lung Nodule. Am J Med 2023; 136:e153-e154. [PMID: 37068572 DOI: 10.1016/j.amjmed.2023.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/19/2023]
Affiliation(s)
- Justin Tao Wen Chiam
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore.
| | - Joo Wei Chua
- Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore; FAST and Chronic Programme, Alexandra Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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25
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Matsuno O. Allergic bronchopulmonary aspergillosis successfully treated with tezepelumab. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2589-2591. [PMID: 37245732 DOI: 10.1016/j.jaip.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/19/2023] [Accepted: 05/14/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Osamu Matsuno
- Department of Allergic and Rheumatoid Disease, Osaka Habikino Medical Center, Habikino City, Osaka, Japan.
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Lionakis MS, Drummond RA, Hohl TM. Immune responses to human fungal pathogens and therapeutic prospects. Nat Rev Immunol 2023; 23:433-452. [PMID: 36600071 PMCID: PMC9812358 DOI: 10.1038/s41577-022-00826-w] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 01/06/2023]
Abstract
Pathogenic fungi have emerged as significant causes of infectious morbidity and death in patients with acquired immunodeficiency conditions such as HIV/AIDS and following receipt of chemotherapy, immunosuppressive agents or targeted biologics for neoplastic or autoimmune diseases, or transplants for end organ failure. Furthermore, in recent years, the spread of multidrug-resistant Candida auris has caused life-threatening outbreaks in health-care facilities worldwide and raised serious concerns for global public health. Rapid progress in the discovery and functional characterization of inborn errors of immunity that predispose to fungal disease and the development of clinically relevant animal models have enhanced our understanding of fungal recognition and effector pathways and adaptive immune responses. In this Review, we synthesize our current understanding of the cellular and molecular determinants of mammalian antifungal immunity, focusing on observations that show promise for informing risk stratification, prognosis, prophylaxis and therapies to combat life-threatening fungal infections in vulnerable patient populations.
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Affiliation(s)
- Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
| | - Rebecca A Drummond
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Tobias M Hohl
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Immunology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Kai Y, Kataoka R, Suzuki K, Takano M, Muro S. Lung cancer resembling allergic bronchopulmonary mycosis with an asthma-like presentation. Respir Med Case Rep 2023; 45:101887. [PMID: 37435548 PMCID: PMC10331302 DOI: 10.1016/j.rmcr.2023.101887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/04/2023] [Accepted: 06/19/2023] [Indexed: 07/13/2023] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a lung disorder caused by a hypersensitivity reaction to antigens of the Aspergillus species. Recently, allergic bronchopulmonary mycosis (ABPM) caused by fungi other than Aspergillus species but with the same symptoms has been described. ABPM commonly affects patients with allergic diseases including bronchial asthma. ABPM is characterized by radiographic appearance, with the most common findings being proximal bronchiectasis and signs of mucoid impaction. However, the differentiation of ABPM is often necessary to enable accurate diagnosis of lung cancer. A 73-year-old man visited the outpatient clinic with symptoms of exertional dyspnea. He was diagnosed with ABPM due to suspicious bronchiectasis and mucoid impaction observed in computed tomography (CT) of his chest. After 3 months, he visited our hospital with continued exertional dyspnea and suspicion of a possible tumor in his lung. Marked eosinophilia and high-attenuation mucus impaction were not taken into consideration as diagnosis was conducted as per clinical diagnostic criteria for ABPA/ABPM. We hereby report a case of lung cancer in a patient initially evaluated for suspected ABPM of the right lung. The diagnosis of lung cancer was established using bronchoscopy. If any definitive diagnosis is not achieved by following the clinical diagnostic criteria for ABPM, physicians should achieve a histological diagnosis by performing a prompt bronchoscopy.
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Affiliation(s)
- Yoshiro Kai
- Department of Respiratory Medicine, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino-gun, Nara, 638-8551, Japan
| | - Ryosuke Kataoka
- Department of Respiratory Medicine, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino-gun, Nara, 638-8551, Japan
| | - Kentaro Suzuki
- Department of Respiratory Medicine, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino-gun, Nara, 638-8551, Japan
| | - Masato Takano
- Department of Diagnostic Pathology, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino-gun, Nara, 638-8551, Japan
| | - Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara, 634-8522, Japan
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Agarwal R, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Soundappan K, Rudramurthy SM, Aggarwal AN, Chakrabarti A. Prevalence of Aspergillus Sensitization and Allergic Bronchopulmonary Aspergillosis in Adults With Bronchial Asthma: A Systematic Review of Global Data. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1734-1751.e3. [PMID: 37088374 DOI: 10.1016/j.jaip.2023.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/01/2023] [Accepted: 04/04/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND The prevalence of allergic bronchopulmonary aspergillosis (ABPA) in asthmatic patients remains unclear and is likely different across geographic locales. OBJECTIVE To systematically review the literature for estimating the prevalence of Aspergillus sensitization (AS) and ABPA in adults with bronchial asthma. METHODS We searched the PubMed and Embase databases for studies reporting the prevalence of AS or ABPA in at least 50 asthmatic subjects. The primary outcome was to assess the prevalence of ABPA. The secondary outcome was to evaluate the prevalence of AS in asthma and that of ABPA in asthma with AS. We pooled the prevalence estimates using a random-effects model and examined the factors influencing the prevalence using multivariate meta-regression. RESULTS Of the 11,801 records retrieved, 86 studies with 25,770 asthmatic subjects met the inclusion criteria. Most of the studies were from tertiary care centers. The pooled prevalence of ABPA in asthma (47 studies; 9822 asthmatic subjects) was 11.3% (95% CI, 8.7-14.2). The pooled prevalence of AS in asthma (73 studies; 23,003 asthmatic subjects) was 25.1% (95% CI, 20.5-30.0), whereas the prevalence of ABPA in AS (36 studies; 2954 asthmatic subjects) was 37.0% (95% CI, 27.9-46.6). Multivariate meta-regression identified studies published from India (odds ratio, 1.11; 95% CI, 1.01-1.23) as the only factor associated with higher ABPA prevalence. There was presence of significant statistical heterogeneity and publication bias. CONCLUSIONS We found a high prevalence of ABPA in adult asthmatic subjects, underscoring the need for screening for ABPA in all asthmatic subjects seeking tertiary care.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (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
| | - Kathirvel Soundappan
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Muthu V, Dhooria S, Sehgal IS, Prasad KT, Rudramurthy SM, Aggarwal AN, Chakrabarti A, Agarwal R. Nebulized amphotericin B for preventing exacerbations in allergic bronchopulmonary aspergillosis: A systematic review and meta-analysis. Pulm Pharmacol Ther 2023; 81:102226. [PMID: 37230237 DOI: 10.1016/j.pupt.2023.102226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 02/09/2023] [Accepted: 05/22/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is complicated by exacerbations in more than one-third of the subjects. Whether nebulized amphotericin B (NAB) therapy prevents ABPA exacerbations remains unclear. OBJECTIVES The primary objective of this systematic review and meta-analysis was to determine the frequency of subjects remaining exacerbation-free, one year after initiating NAB. The key secondary objectives were the time to first exacerbation and the safety of NAB therapy. METHODS We searched the PubMed and Embase databases for studies evaluating ≥5 subjects of ABPA managed with NAB. We report the pooled proportion of ABPA subjects remaining exacerbation free after one year. For the randomized controlled trials (RCTs), we estimate the pooled risk difference (RD) of exacerbation-free status at one year with NAB versus the control arm. RESULTS We included five studies for our analysis; three were observational (n = 28) and two RCTs (n = 160). The pooled proportion (95% confidence interval [CI]) of subjects remaining exacerbation free with NAB at one year was 76% (62-88). The pooled RD (95% CI) of an exacerbation-free status at one year was 0.33 (-0.12 to 0.78) and was not significantly different between the NAB and control arms. The time to first exacerbation was longer with NAB than with the standard therapy. No serious adverse events were reported with NAB. CONCLUSION NAB does not improve exacerbation-free status at one year; however, weak evidence suggests it delays ABPA exacerbations. More research using different dosing regimens is required.
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Affiliation(s)
- Valliappan Muthu
- 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
| | - Inderpaul Singh Sehgal
- 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
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Pulmonary Medicine, Doodhadhari Burfani Hospital, Haridwar, Uttarakhand, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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Cottin V. Eosinophilic Lung Diseases. Immunol Allergy Clin North Am 2023; 43:289-322. [PMID: 37055090 DOI: 10.1016/j.iac.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
The eosinophilic lung diseases may manifest as chronic eosinophilic pneumonia, acute eosinophilic pneumonia, or as the Löffler syndrome (generally of parasitic etiology). The diagnosis of eosinophilic pneumonia is made when both characteristic clinical-imaging features and alveolar eosinophilia are present. Peripheral blood eosinophils are generally markedly elevated; however, eosinophilia may be absent at presentation. Lung biopsy is not indicated except in atypical cases after multidisciplinary discussion. The inquiry to possible causes (medications, toxic drugs, exposures, and infections especially parasitic) must be meticulous. Idiopathic acute eosinophilic pneumonia may be misdiagnosed as infectious pneumonia. Extrathoracic manifestations raise the suspicion of a systemic disease especially eosinophilic granulomatosis with polyangiitis. Airflow obstruction is frequent in allergic bronchopulmonary aspergillosis, idiopathic chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis, and hypereosinophilic obliterative bronchiolitis. Corticosteroids are the cornerstone of therapy, but relapses are common. Therapies targeting interleukin 5/interleukin-5 are increasingly used in eosinophilic lung diseases.
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Affiliation(s)
- Vincent Cottin
- Service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Centre de référence coordonnateur des maladies pulmonaires rares (OrphaLung), 28 Avenue Doyen Lepine, Lyon Cedex 69677, France; Université Lyon 1, INRAE, UMR754, Lyon, France.
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Cheng BH, Xiao X, Jin Y, Li J. Editorial: Mechanisms and advances in respiratory allergic diseases. Front Immunol 2023; 14:1186301. [PMID: 37056762 PMCID: PMC10086316 DOI: 10.3389/fimmu.2023.1186301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Affiliation(s)
- Bao-Hui Cheng
- Department of Otolaryngology, Longgang E.N.T Hospital & Shenzhen Key Laboratory of E.N.T, Institute of Ear Nose Throat (E.N.T), Shenzhen, China
| | - Xiaojun Xiao
- Institute of Allergy and Immunology, Health Science Center, Shenzhen University, Shenzhen, China
| | - Yu Jin
- Department of Pathology, Yale University, New Haven, CT, United States
| | - Jing Li
- Department of Allergy and Clinical Immunology, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Oliveira M, Oliveira D, Lisboa C, Boechat JL, Delgado L. Clinical Manifestations of Human Exposure to Fungi. J Fungi (Basel) 2023; 9:jof9030381. [PMID: 36983549 PMCID: PMC10052331 DOI: 10.3390/jof9030381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Biological particles, along with inorganic gaseous and particulate pollutants, constitute an ever-present component of the atmosphere and surfaces. Among these particles are fungal species colonizing almost all ecosystems, including the human body. Although inoffensive to most people, fungi can be responsible for several health problems, such as allergic fungal diseases and fungal infections. Worldwide fungal disease incidence is increasing, with new emerging fungal diseases appearing yearly. Reasons for this increase are the expansion of life expectancy, the number of immunocompromised patients (immunosuppressive treatments for transplantation, autoimmune diseases, and immunodeficiency diseases), the number of uncontrolled underlying conditions (e.g., diabetes mellitus), and the misusage of medication (e.g., corticosteroids and broad-spectrum antibiotics). Managing fungal diseases is challenging; only four classes of antifungal drugs are available, resistance to these drugs is increasing, and no vaccines have been approved. The present work reviews the implications of fungal particles in human health from allergic diseases (i.e., allergic bronchopulmonary aspergillosis, severe asthma with fungal sensitization, thunderstorm asthma, allergic fungal rhinosinusitis, and occupational lung diseases) to infections (i.e., superficial, subcutaneous, and systemic infections). Topics such as the etiological agent, risk factors, clinical manifestations, diagnosis, and treatment will be revised to improve the knowledge of this growing health concern.
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Affiliation(s)
- Manuela Oliveira
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal
- Ipatimup-Instituto de Patologia e Imunologia Molecular da Universidade do Porto, Rua Júlio Amaral de Carvalho 45, 4200-135 Porto, Portugal
| | - Diana Oliveira
- CRN-Unidade de Reabilitação AVC, Centro de Reabilitação do Norte, Centro Hospitalar de Vila Nova de Gaia/Espinho, Avenida dos Sanatórios 127, 4405-565 Vila Nova de Gaia, Portugal
| | - Carmen Lisboa
- Serviço de Microbiologia, Departamento de Patologia, Faculdade de Medicina do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Serviço de Dermatologia, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- CINTESIS@RISE-Centro de Investigação em Tecnologias e Serviços de Saúde, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - José Laerte Boechat
- CINTESIS@RISE-Centro de Investigação em Tecnologias e Serviços de Saúde, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Luís Delgado
- CINTESIS@RISE-Centro de Investigação em Tecnologias e Serviços de Saúde, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Laboratório de Imunologia, Serviço de Patologia Clínica, Centro Hospitalar e Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
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Tackling the cytokine storm using advanced drug delivery in allergic airway disease. J Drug Deliv Sci Technol 2023. [DOI: 10.1016/j.jddst.2023.104366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
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Aspergillus Sensitization and Allergic Bronchopulmonary Aspergillosis in Asthmatic Children: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2023; 13:diagnostics13050922. [PMID: 36900068 PMCID: PMC10001349 DOI: 10.3390/diagnostics13050922] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Background: The prevalence of aspergillus sensitization (AS) and allergic bronchopulmonary aspergillosis (ABPA) in asthmatic children remains unclear. Objective: To systematically review the literature to estimate the prevalence of AS and ABPA in children with bronchial asthma. Methods: We searched the PubMed and Embase databases for studies reporting the prevalence of AS or ABPA in pediatric asthma. The primary outcome was to assess the prevalence of AS, while the secondary outcome was to evaluate the prevalence of ABPA. We pooled the prevalence estimates using a random effects model. We also calculated the heterogeneity and publication bias. Results: Of the 11,695 records retrieved, 16 studies with 2468 asthmatic children met the inclusion criteria. Most studies were published from tertiary centers. The pooled prevalence of AS in asthma (15 studies; 2361 subjects) was 16.1% (95% confidence intervals [CI], 9.3-24.3). The prevalence of AS was significantly higher in prospective studies, studies from India, and those from developing countries. The pooled prevalence of ABPA in asthma (5 studies; 505 children) was 9.9% (95% CI, 0.81-27.6). There was significant heterogeneity and publication bias for both outcomes. Conclusions: We found a high prevalence of AS and ABPA in asthmatic children. There is a need for community-based studies from different ethnicities using a standard methodology to ascertain the true prevalence of AS and ABPA in pediatric asthma.
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Sehgal IS, Dhooria S, Soundappan K, Rudramurthy SM, Chakrabarti A, Agarwal R. Comparison of three sample types for performing LDBio Aspergillus immunochromatographic technology lateral flow assay for IgG/IgM antibody detection in chronic aspergillosis. Clin Microbiol Infect 2023; 29:404-405. [PMID: 36529158 DOI: 10.1016/j.cmi.2022.11.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/26/2022] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
Affiliation(s)
- 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
| | - Kathirvel Soundappan
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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Bravo-Queipo-de-Llano B, Bonet D, Del Rosal T, Cámara C, Ruiz de Valbuena M, Pérez A, Grasa CD, Méndez-Echevarría A. A challenging differential diagnosis in a patient with autosomal dominant STAT3 deficiency. Pediatr Pulmonol 2023; 58:585-591. [PMID: 36267002 DOI: 10.1002/ppul.26212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/04/2022] [Accepted: 10/13/2022] [Indexed: 01/25/2023]
Abstract
Autosomal dominant hyper IgE syndrome (AD-HIES) is a primary immunodeficiency caused by loss-of-function (LOF) mutations in the Signal Transducer and Activator of Transcription 3 (STAT3) gene. In these patients, performing a correct differential diagnosis of pulmonary infections is difficult and challenging, as they usually have atypical presentations. However, establishing a correct diagnostic and therapeutic approach is essential, as pulmonary complications are responsible for high morbidity and mortality rates in these patients. We report the case of a teenage girl with AD-HIES and respiratory symptoms and fever in whom performing a correct differential diagnosis was challenging.
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Affiliation(s)
| | - Daniel Bonet
- Department of Pediatric Infectious and Tropical Diseases, Hospital La Paz, Madrid, Spain
| | - Teresa Del Rosal
- Department of Pediatric Infectious and Tropical Diseases, Hospital La Paz, Madrid, Spain.,Center for Biomedical, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain.,Network Research on Rare Diseases (CIBERER U767), Instituto de Salud Carlos III, (ISCIII), Madrid, Spain
| | - Carmen Cámara
- Department of Immunology, La Paz University Hospital, Madrid, Spain
| | | | - Ana Pérez
- Department of Pediatric Radiology, La Paz University Hospital, Madrid, Spain
| | - Carlos D Grasa
- Department of Pediatric Infectious and Tropical Diseases, Hospital La Paz, Madrid, Spain.,Center for Biomedical, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain.,Network Research on Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, (ISCIII), Madrid, Spain
| | - Ana Méndez-Echevarría
- Department of Pediatric Infectious and Tropical Diseases, Hospital La Paz, Madrid, Spain.,Center for Biomedical, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain.,Network Research on Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, (ISCIII), Madrid, Spain
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Crossen AJ, Ward RA, Reedy JL, Surve MV, Klein BS, Rajagopal J, Vyas JM. Human Airway Epithelium Responses to Invasive Fungal Infections: A Critical Partner in Innate Immunity. J Fungi (Basel) 2022; 9:40. [PMID: 36675861 PMCID: PMC9862202 DOI: 10.3390/jof9010040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/09/2022] [Accepted: 12/26/2022] [Indexed: 12/29/2022] Open
Abstract
The lung epithelial lining serves as the primary barrier to inhaled environmental toxins, allergens, and invading pathogens. Pulmonary fungal infections are devastating and carry high mortality rates, particularly in those with compromised immune systems. While opportunistic fungi infect primarily immunocompromised individuals, endemic fungi cause disease in immune competent and compromised individuals. Unfortunately, in the case of inhaled fungal pathogens, the airway epithelial host response is vastly understudied. Furthering our lack of understanding, very few studies utilize primary human models displaying pseudostratified layers of various epithelial cell types at air-liquid interface. In this review, we focus on the diversity of the human airway epithelium and discuss the advantages and disadvantages of oncological cell lines, immortalized epithelial cells, and primary epithelial cell models. Additionally, the responses by human respiratory epithelial cells to invading fungal pathogens will be explored. Future investigations leveraging current human in vitro model systems will enable identification of the critical pathways that will inform the development of novel vaccines and therapeutics for pulmonary fungal infections.
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Affiliation(s)
- Arianne J. Crossen
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Rebecca A. Ward
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jennifer L. Reedy
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Manalee V. Surve
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Bruce S. Klein
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706, USA
- Department of Medical Microbiology and Immunology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Jayaraj Rajagopal
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Stem Cell Institute, Cambridge, MA 02138, USA
- Klarman Cell Observatory, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA 02142, USA
| | - Jatin M. Vyas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
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Recent Advances in the Allergic Cross-Reactivity between Fungi and Foods. J Immunol Res 2022; 2022:7583400. [PMID: 36249419 PMCID: PMC9568318 DOI: 10.1155/2022/7583400] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/29/2022] [Accepted: 09/19/2022] [Indexed: 12/03/2022] Open
Abstract
Airborne fungi are one of the most ubiquitous kinds of inhalant allergens which can result in allergic diseases. Fungi tend to grow in warm and humid environments with regional and seasonal variations. Their nomenclature and taxonomy are related to the sensitization of immunoglobulin E (IgE). Allergic cross-reactivity among different fungal species appears to be widely existing. Fungus-related foods, such as edible mushrooms, mycoprotein, and fermented foods by fungi, can often induce to fungus food allergy syndrome (FFAS) by allergic cross-reactivity with airborne fungi. FFAS may involve one or more target organs, including the oral mucosa, the skin, the gastrointestinal and respiratory tracts, and the cardiovascular system, with various allergic symptoms ranging from oral allergy syndrome (OAS) to severe anaphylaxis. This article reviews the current knowledge on the field of allergic cross-reactivity between fungal allergens and related foods, as well as the diagnosis and treatment on FFAS.
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Agarwal R, Sehgal IS, Muthu V, Dhooria S, Prasad KT, Aggarwal AN. Estimating the minimal important difference in FEV 1for patients with allergic bronchopulmonary aspergillosis. Eur Respir J 2022; 60:13993003.01242-2022. [DOI: 10.1183/13993003.01242-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/26/2022] [Indexed: 11/05/2022]
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40
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Agarwal R, Sehgal IS, Muthu V, Dhooria S, Prasad KT, Aggarwal AN, Chakrabarti A. Estimating the clinically important change for Saint George's Respiratory Questionnaire in allergic bronchopulmonary aspergillosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2456-2458.e1. [PMID: 35690366 DOI: 10.1016/j.jaip.2022.05.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/26/2022] [Accepted: 05/26/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Chen H, Zhang X, Zhu L, An N, Jiang Q, Yang Y, Ma D, Yang L, Zhu R. Clinical and immunological characteristics of Aspergillus fumigatus-sensitized asthma and allergic bronchopulmonary aspergillosis. Front Immunol 2022; 13:939127. [PMID: 35983066 PMCID: PMC9379317 DOI: 10.3389/fimmu.2022.939127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Aspergillus fumigatus (A.f) is a common airborne allergen that contributes to allergic asthma. In some patients, A.f can colonize in the airway and lead to allergic bronchopulmonary aspergillosis (ABPA). However, our understanding of the pathogenesis of A.f-sensitized asthma and ABPA remains inadequate. Objective We aimed to investigate the clinical and immunological characteristics of A.f-sensitized asthma and ABPA. Methods A total of 64 ABPA and 57 A.f-sensitized asthma patients were enrolled in the study, and 33 non-A.f-sensitized asthma patients served as the control group. The clinical and immunological parameters included lung function, fractional exhaled nitric oxide (FeNO), induced sputum and blood cell analysis, specific IgE/IgG/IgA of A.f and its components, cytokines (IL-33, IL-25, and TSLP) and CD4+T cell subsets. Results The eosinophils in blood, induced sputum, and FeNO were significantly higher in ABPA patients compared to that in A.f-sensitized patients. The combination of FeNO and eosinophils (EO) parameters presented good diagnostic efficiency in differentiating A.f (+) asthma from ABPA, with a sensitivity of 80% and a specificity of 100%. Specific IgE, IgG, and IgA against A.f also increased in ABPA patients. However, serum IL-25, IL-33, and TSLP showed no significant differences between the two groups. Cell analysis showed an increase in IFN-γ+Th1 cells in the ABPA patients. FlowSOM analysis further confirmed that the frequency of CD3+CD4+PD-1+CD127+IFN-γ+T cells was higher in ABPA patients. Conclusion Our findings suggest the distinct humoral and cell immunological responses in A.f-sensitized asthma and ABPA patients. ABPA patients have more severe eosinophilic inflammation and enhanced Th1 responses compared with A.f-sensitized asthma patients.
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Affiliation(s)
- Hao Chen
- Department of Allergy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinyu Zhang
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Li Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nairui An
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qing Jiang
- Department of Allergy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yaqi Yang
- Department of Allergy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dongxia Ma
- Department of Allergy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Yang
- Department of Allergy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Rongfei Zhu, ; Lin Yang,
| | - Rongfei Zhu
- Department of Allergy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Rongfei Zhu, ; Lin Yang,
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Sehgal IS, Dhooria S, Prasad KT, Muthu V, Aggarwal AN, Agarwal R. Comparative diagnostic accuracy of immunoprecipitation versus immunoassay methods for detecting A.fumigatus-specific IgG in allergic bronchopulmonary aspergillosis: a systematic review and meta-analysis. Mycoses 2022; 65:866-876. [PMID: 35757847 DOI: 10.1111/myc.13488] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The diagnostic accuracy of immunoassays versus immunoprecipitation methods for detecting A.fumigatus-specific IgG in patients with allergic bronchopulmonary aspergillosis (ABPA) complicating asthma remains unclear. METHODS We performed a systematic review to identify studies describing both the methods in the same ABPA subjects. We assessed study quality using the QUADAS-2 tool. We derived the relative sensitivity and specificity using the HSROC meta-regression model. We calculated the number-needed-to-test using an immunoassay to detect one additional positive test in ABPA. RESULTS Our search yielded 20 studies (796 ABPA, 929 controls). The studies had a high risk of bias. The summary estimates for sensitivity and specificity of immunoprecipitation methods were 68.6% (95% CI, 48.4-83.5) and 93.8% (95% CI, 83.6-97.8), while for immunoassays they were 85.2% (95% CI, 73.3-92.3) and 84.6% (95% CI, 76.0-90.5), respectively. The relative sensitivity and specificity of immunoassays compared to immunoprecipitation tests were 1.29 (95% CI, 1.1-1.6) and 0.91 (95% CI, 0.85-0.97), respectively. The automated immunoassays (1.77; 95% CI, 1.1-2.8) had better relative sensitivity than the manual (1.1; 95% CI, 1.02-1.18) assays compared to immunoprecipitation. The relative specificity of manual immunoassays (0.95; 95% CI, 0.91-0.99) was significantly lower, while that of automated (0.88; 95% CI, 0.77-1.0) assays was lower but not statistically different. One additional positive result was detected for every 6 (95% CI, 5-7) tests performed with immunoassay (versus immunoprecipitation). CONCLUSION Manual immunoassays have higher sensitivity and lower specificity, while automated immunoassays have higher sensitivity and similar specificity than immunoprecipitation methods for detecting A.fumigatus-IgG in patients with ABPA.
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Affiliation(s)
- 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
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Kanaujia R, Arora A, Chakrabarti A, Rudramurthy SM, Agarwal R. Occurrence of Cystic Fibrosis Transmembrane Conductance Regulator Gene Mutations in Patients with Allergic Bronchopulmonary Aspergillosis Complicating Asthma. Mycopathologia 2022; 187:147-155. [DOI: 10.1007/s11046-022-00631-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/31/2022] [Indexed: 11/25/2022]
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Agarwal R, Saxena P, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Aggarwal AN, Chakrabarti A. Evaluation of Simpler Criteria for Diagnosing Allergic Bronchopulmonary Aspergillosis Complicating Asthma. Front Cell Infect Microbiol 2022; 12:861866. [PMID: 35402294 PMCID: PMC8990730 DOI: 10.3389/fcimb.2022.861866] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background The modified International Society for Human and Animal Mycology (ISHAM) allergic bronchopulmonary aspergillosis (ABPA) working group (AWG) criteria lists up to five components for diagnosing ABPA in asthmatics. Whether eliminating specific components of the existing criteria would have the same diagnostic utility as the original remains unknown. Objective To evaluate the performance of several simplified criteria for diagnosing ABPA. Methods We compared the performance of seven new criteria (after excluding or modifying one or more of the components of the ISHAM-AWG criteria) with the modified ISHAM-AWG criteria in asthmatic subjects using latent class analysis (LCA). We also tested the performance of the newer criteria using accuracy measures against a multidisciplinary team (MDT) diagnosis of ABPA. We considered the diagnostic accuracy of the newer criteria to be acceptable if the correct classification and false-negative rates were >95% and <5%, respectively, on an MDT evaluation. Results We analyzed data from 543 asthmatic subjects (58.8% women; mean age, 36.8 years). Using LCA, the sensitivity of the A.fumigatus-specific IgE-based criteria ranged from 92-99%, while the specificity varied between 92% and 100%. The MDT diagnosed ABPA in 106 (19.5%) subjects. Using MDT as the reference standard, the correct classification and false-negative rates were >95% for three of the seven and <5% for four of the seven newer criteria. Conclusions We found several of the newly developed criteria to perform, like the modified ISHAM-AWG criteria, for diagnosing ABPA complicating asthma. A prospective study in current clinical algorithms is required for validating our observations.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Puneet Saxena
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (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
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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