Radiologic Criteria for the Diagnosis of High-Attenuation Mucus in Allergic Bronchopulmonary Aspergillosis

Allergic Bronchopulmonary Mycosis Complicated with Lung Adenocarcinoma

Chest computed tomography (CT) of a 76-year-old woman with bronchial asthma showed multiple lung nodules with high CT densities that were compatible with high-attenuation mucoid (HAM) impactions characteristic of allergic bronchopulmonary mycosis (ABPM). Follow-up chest CT revealed increased sizes of multiple lung nodules. However, a left upper lobe nodule showed lower CT density than the other HAM impactions. A transbronchial lung biopsy of that upper lobe nodule revealed lung adenocarcinoma. Measuring the CT density is important for the differential diagnosis of lung nodules when following ABPM patients. Our patient's increased serum carcinoembryonic antigen levels were associated with peripheral blood eosinophilia. Mucoid impaction in the lung was positively stained with carcinoembryonic antigen and showed the distribution of eosinophilic granules.

Aspergillus-related lung disease in people with cystic fibrosis: can imaging help us to diagnose disease?

In people with cystic fibrosis (PwCF), viscous sputum and dysfunction of the mucociliary escalator leads to early and chronic infections. The prevalence of Aspergillus fumigatus in sputum is high in PwCF and the contribution of A. fumigatus to the progression of structural lung disease has been reported. However, overall, relatively little is known about the contribution of A. fumigatus to CF lung disease. More knowledge is needed to aid clinical decisions on whether to start antifungal treatment. In this review, we give an overview of A. fumigatus colonisation and infection in PwCF and the different types of pulmonary disease caused by it. Furthermore, we discuss the current evidence for structural lung damage associated with A. fumigatus in PwCF on chest computed tomography and magnetic resonance imaging. We conclude that radiological outcomes to identify disease caused by A. fumigatus can be important for clinical studies and management.

Epidemiology and outcomes of allergic bronchopulmonary aspergillosis in the elderly

BACKGROUND

The prevalence and outcomes of allergic bronchopulmonary aspergillosis (ABPA) in the elderly remain unknown.

METHODS

We reviewed our database to identify the proportion of subjects diagnosed with ABPA at ≥60 years of age (ABPA-elderly). We compared the clinical features, treatment and outcomes of ABPA-elderly versus the non-elderly (ABPA diagnosed at <60 years of age).

RESULTS

Between 2007 and 2019, we encountered 810 ABPA subjects with a mean age of 34.9 years (49.4% women). Of these, 43 (5.3%) were aged ≥60 years (ABPA-elderly). There was a trend towards lower median (interquartile range [IQR]) serum total IgE (4900 [2659-10000] vs. 7156 [23360-11963] IU/mL; P = .06) and Aspergillus fumigatus-specific IgE (12.3 [4.8-29.6] vs. 22.4 [7.7-41.5] kUA/L; P = .06) in the elderly than the non-elderly. Eosinophil counts were similar in the two groups. The median [IQR] number of segments involved by bronchiectasis (5 [2-9] vs. 7 [4-11]) was significantly lower in the ABPA-elderly (P = .001). The proportion of subjects experiencing ABPA exacerbations was significantly (P = .047) lower in the elderly (25.6%) vs. the non-elderly (40.8%). There was also a tendency towards a lower mean number of exacerbations in the elderly (155 vs. 208 exacerbation per 1000 person-years) than the non-elderly (P = .09). There was also a trend towards longer mean time to first exacerbation in the ABPA-elderly than the non-elderly (1612 vs. 1159 days).

CONCLUSION

ABPA was uncommon in the elderly. The bronchiectasis is less extensive with a trend towards lower immunological severity and fewer exacerbations in the elderly than the non-elderly subjects with ABPA.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is an inflammatory disease caused by immunologic reactions initiated against Aspergillus fumigatus colonizing the airways of patients with asthma and cystic fibrosis. The common manifestations include treatment-resistant asthma, transient and fleeting pulmonary opacities and bronchiectasis. It is believed that globally there are about five million cases of ABPA, with India alone accounting for about 1.4 million cases. The occurrence of ABPA among asthmatic patients in special clinics may be as high as 13 per cent. Thus, a high degree of suspicion for ABPA should be entertained while treating a patient with bronchial asthma, particularly in specialized clinics. Early diagnosis and appropriate treatment can delay (or even prevent) the onset of bronchiectasis, which suggests that all patients of bronchial asthma should be screened for ABPA, especially in chest clinics. The current review summarizes the recent advances in the pathogenesis, diagnosis and management of ABPA.

Diagnostic Cutoffs and Clinical Utility of Recombinant Aspergillus fumigatus Antigens in the Diagnosis of Allergic Bronchopulmonary Aspergillosis

BACKGROUND

The clinical utility of IgE against recombinant Aspergillus fumigatus (rAsp)-specific antigens in allergic bronchopulmonary aspergillosis (ABPA) remains unclear.

OBJECTIVE

To identify the optimal diagnostic cutoffs of rAsp-specific IgE in differentiating ABPA from A fumigatus-sensitized asthma (ASA), and define their utility in the diagnosis of ABPA.

METHODS

We enrolled consecutive subjects with ASA and ABPA. IgE against rAsp f1, f2, f3, f4, and f6 was assayed in all the subjects. We evaluated 3 fixed cutoffs (0.35, 0.5, and 1.0 kU_A/L) for their diagnostic performance in the entire cohort. We also divided the study population into derivation and validation cohorts. Cutoffs for rAsp-specific IgE were obtained using the receiver-operating characteristic analysis in the derivation cohort. We then evaluated the diagnostic performance of these cutoffs in the validation cohort. We further correlated rAsp-specific IgE levels in ABPA with asthma control, spirometry, imaging, and immunologic markers.

RESULTS

We included 194 subjects (123 ABPA and 71 ASA). The statistically derived cutoffs proved superior to fixed cutoffs. IgE against rAsp f1 yielded the best combination of sensitivity (89%) and specificity (100%). The sensitivity and specificity of IgE against either rAsp f1 (cutoff, 4.465 kU_A/L) or f2 (cutoff, 1.300 kU_A/L) for diagnosing ABPA were 100% and 81%, respectively. The correlation between rAsp-specific IgE and most clinical parameters of ABPA was weak.

CONCLUSIONS

IgE against rAsp f1 and f2 (using receiver-operating characteristic-derived cutoffs) were found to be the most useful in differentiating ABPA from ASA. Because this study was conducted at a single center, our results require further validation.