1
|
Denton E, Wark P, Hew M. Allergic broncho-pulmonary aspergillosis: Old disease, new frontiers. Respirology 2024. [PMID: 38887939 DOI: 10.1111/resp.14775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 06/05/2024] [Indexed: 06/20/2024]
Affiliation(s)
- Eve Denton
- Allergy, Asthma & Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Wark
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
- Cystic Fibrosis Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Cai C, Qu J, Zhou J. Effectiveness and safety of omalizumab in patients with allergic bronchopulmonary aspergillosis with or without allergic rhinitis: a retrospective chart review. BMC Pulm Med 2023; 23:389. [PMID: 37833657 PMCID: PMC10571511 DOI: 10.1186/s12890-023-02696-x] [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: 05/07/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Omalizumab is a valuable alternative treatment for allergic bronchopulmonary aspergillosis (ABPA). The effectiveness and safety of this medication have not been confirmed. The main purpose of this study was to evaluate the effectiveness and safety of omalizumab for ABPA. METHODS This study involved a retrospective chart review. The main indicators used were asthma control test (ACT) scores, lung function parameters, doses of corticosteroids, acute exacerbation, hospitalization rates, total serum immunoglobulin E (IgE) levels, and blood eosinophil counts. Related adverse events were also reviewed to evaluate the safety of omalizumab. RESULTS Fourteen patients with ABPA were included, of whom 10 (71%) concurrently had allergic rhinitis (AR). There were improvements in the mean percentages of the forced vital capacity, percentages of the forced expiratory volume in 1 s, and ACT score after omalizumab administration (p < 0.05, p < 0.01, and p < 0.01, respectively). After the initiation of omalizumab administration, the median corticosteroid dose, acute exacerbation rate, hospitalization rate, and mean blood eosinophil count decreased when compared with the baseline values (p < 0.05, p < 0.05, p < 0.01, and p < 0.05, respectively). A reduction in the total serum IgE level was observed in patients with ABPA without AR compared with that in patients with AR (p < 0.05). One patient reported a concurrent skin rash, which spontaneously resolved without medication. CONCLUSION It is safe and effective to prescribe omalizumab to patients with ABPA, irrespective of whether they have AR. Dose adjustment of omalizumab is safe after disease control. The total serum IgE level might be a predictor of the effectiveness of omalizumab in patients without AR.
Collapse
Affiliation(s)
- Cuihong Cai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, 310003, People's Republic of China
| | - Jingjing Qu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, 310003, People's Republic of China
| | - Jianying Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, 310003, People's Republic of China.
| |
Collapse
|
5
|
Denning DW, Pfavayi LT. Poorly controlled asthma - Easy wins and future prospects for addressing fungal allergy. Allergol Int 2023; 72:493-506. [PMID: 37544851 DOI: 10.1016/j.alit.2023.07.003] [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: 06/05/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 08/08/2023] Open
Abstract
Poorly controlled asthma is especially common in low resource countries. Aside from lack of access to, or poor technique with, inhaled beta-2 agonists and corticosteroids, the most problematic forms of asthma are frequently associated with both fungal allergy and exposure, especially in adults leading to more asthma exacerbations and worse asthma. The umbrella term 'fungal asthma' describes many disorders linked to fungal exposure and/or allergy to fungi. One fungal asthma endotype, ABPA, is usually marked by a very high IgE and its differential diagnosis is reviewed. Both ABPA and fungal bronchitis in bronchiectasis are marked by thick excess airway mucus production. Dermatophyte skin infection can worsen asthma and eradication of the skin infection improves asthma. Exposure to fungi in the workplace, home and schools, often in damp or water-damaged buildings worsens asthma, and remediation improves symptom control and reduces exacerbations. Antifungal therapy is beneficial for fungal asthma as demonstrated in nine of 13 randomised controlled studies, reducing symptoms, corticosteroid need and exacerbations while improving lung function. Other useful therapies include azithromycin and some biologics approved for the treatment of severe asthma. If all individuals with poorly controlled and severe asthma could be 'relieved' of their fungal allergy and infection through antifungal therapy without systemic corticosteroids, the health benefits would be enormous and relatively inexpensive, improving the long term health of over 20 million adults and many children. Antifungal therapy carries some toxicity, drug interactions and triazole resistance risks, and data are incomplete. Here we summarise what is known and what remains uncertain about this complex topic.
Collapse
Affiliation(s)
- David W Denning
- Manchester Fungal Infection Group, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK.
| | - Lorraine T Pfavayi
- Institute of Immunology & Infection Research, Ashworth Laboratories, School of Biological Sciences, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Bergagnini-Kolev M, Kane K, Templeton IE, Curran AK. Evaluation of the Potential for Drug-Drug Interactions with Inhaled Itraconazole Using Physiologically Based Pharmacokinetic Modelling, Based on Phase 1 Clinical Data. AAPS J 2023; 25:62. [PMID: 37344751 DOI: 10.1208/s12248-023-00828-z] [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: 03/08/2023] [Accepted: 06/02/2023] [Indexed: 06/23/2023] Open
Abstract
Itraconazole is a potent inhibitor of cytochrome P450 3A4 (CYP3A4), associated with numerous drug-drug interactions (DDI). PUR1900, a dry powder formulation of itraconazole for oral inhalation, results in high lung and low systemic exposure. This project used physiologically based pharmacokinetic (PBPK) modeling to assess the DDI potential of inhaled PUR1900, using midazolam as a "victim drug." The basic and mechanistic static models evaluated the DDI potential of PUR1900, assuming 5 mg of midazolam coadministration at steady-state itraconazole exposure. Subsequently, Simcyp® PBPK simulation software and pharmacokinetic data from a Phase 1 clinical trial with PUR1900 (NCT03479411) were used to optimize an existing itraconazole PBPK model. The model was applied to investigate the potential for CYP3A4 DDI when 5 mg of midazolam is co-administered with inhaled PUR1900 at a steady state in a virtual healthy population at PUR1900 doses up to 40 mg per day. The basic static and mechanistic static models suggested a strong likelihood for DDI with inhaled PUR1900. The PBPK model was consistent with PUR1900 Phase 1 trial data. The geometric mean Cmax and AUC ratios of midazolam at a maximum dose of 40 mg PUR1900 were 1.14 and 1.26, respectively, indicating a minimal likelihood of DDI with inhaled PUR1900. The low systemic exposure of itraconazole when administered as PUR1900 results in minimal to no CYP3A4 inhibition, reducing the concern of drug-drug interactions. As the risk of CYP3A4 DDI is predicted to be significantly lower when itraconazole is administered via oral inhalation as PUR1900, it is likely that PUR1900 can be safely used for the treatment of pulmonary fungal infections in patients taking pharmaceuticals currently contraindicated with oral itraconazole.
Collapse
Affiliation(s)
| | - Katie Kane
- Pulmatrix, Inc, 36 Crosby Drive, Suite 100, Bedford, MA, 01730, USA
| | | | - Aidan K Curran
- Pulmatrix, Inc, 36 Crosby Drive, Suite 100, Bedford, MA, 01730, USA.
| |
Collapse
|
8
|
Mathew JL, Kumar K, Agrawal S, Bafna S, Bhatt S, Chatterjee P, Chithambaram NS, Das RR, Gupta H, Gupta S, Jat KR, Kalyan P, Kapoor R, Kaur H, Kaur J, Kaur S, Kulkarni SP, Kumar A, Rawat SS, Saxena V, Singh A, Sivabalan S, Srivastava S, Tayal A. Evidence-Based Guidelines for the Management of Allergic Bronchopulmonary Aspergillosis (ABPA) in Children and Adolescents with Asthma. Indian J Pediatr 2023:10.1007/s12098-023-04592-y. [PMID: 37264275 DOI: 10.1007/s12098-023-04592-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/17/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) frequently complicates asthma. There is urgent need to develop evidence-based guidelines for the management of ABPA in children. The Evidence Based Guideline Development Group (EBGDG) of the Indian Academy of Pediatrics (IAP) National Respiratory Chapter (NRC) addressed this need. METHODS The EBGDG shortlisted clinical questions relevant to the management of ABPA in asthma. For each question, the EBGDG undertook a systematic, step-wise evidence search for existing guidelines, followed by systematic reviews, followed by primary research studies. The evidence was collated, critically appraised, and synthesized. The EBGDG worked through the Evidence to Decision (EtD) framework, to formulate recommendations, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS Seven clinical questions were prioritized, and the following recommendations formulated. (1) Children with poorly controlled asthma should be investigated for ABPA (conditional recommendation, moderate certainty of evidence). (2) Low dose steroid therapy regimen (0.5 mg/kg/d for the first 2 wk, followed by a progressive tapering) is preferable to higher dose regimens (conditional recommendation, very low certainty of evidence). (3) Oral steroid regimens longer than 16 wk (including tapering), should not be used (conditional recommendation, very low certainty of evidence). (4) Antifungals may or may not be added to steroid therapy as the evidence was neither in favour nor against (conditional recommendation, low certainty of evidence). (5) For clinicians using antifungal agents, the EBGDG recommends against using voriconazole instead of itraconazole (conditional recommendation, very low certainty of evidence). (6) No evidence-based recommendation could be framed for using pulse steroid therapy in preference to conventional steroid therapy. (7) Immunotherapy with biologicals including omalizumab or dupilumab is not recommended (conditional recommendation, very low certainty of evidence). CONCLUSIONS This evidence-based guideline can be used by healthcare providers in diverse clinical settings.
Collapse
Affiliation(s)
- Joseph L Mathew
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Ketan Kumar
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Sheetal Agrawal
- Department of Pediatrics, ABVIMS and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Sanjay Bafna
- Department of Pediatrics, Bharati Vidyapeeth Medical College Hospital & Jehangir Hospital, Pune, India
| | - Sonia Bhatt
- Department of Pediatrics, F H Medical College, Etmaadpur, Agra, India
| | - Pallab Chatterjee
- Department of Pediatrics, Apollo Multispeciality Hospital, Kolkata, India
| | - N S Chithambaram
- Department of Pediatrics, Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Hema Gupta
- Department of Pediatrics, ABVIMS and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Sarika Gupta
- Department of Pediatrics, King George's Medical University, Lucknow, India
| | - Kana Ram Jat
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Pawan Kalyan
- Department of Pediatrics, Dr Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Chinaoutapally, India
| | - Rashmi Kapoor
- Department of Pediatrics, Regency Hospital Ltd., Kanpur, India
| | - Hardeep Kaur
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jasmeet Kaur
- Department of Pediatrics, Sri Balaji Action Medical Institute, New Delhi, India
| | - Satnam Kaur
- Department of Pediatrics, VMMC & Safdarjung Hospital, New Delhi, India
| | - Suhas P Kulkarni
- Department of Pediatrics, D. Y. Patil Medical College, D. Y, Patil Education Society (Deemed to be University), Kolhapur, Maharashtra, India
| | - Amber Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, India
| | | | - Vivek Saxena
- Department of Pediatrics, Vatsalya Hospital, Kanpur, India
| | - Anita Singh
- Department of Pediatrics, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
| | - Somu Sivabalan
- Department of Pediatrics, Dr Rela Institute & Medical Centre (RIMC), Chrompet, Chennai; and Sundaram Medical Foundation (SMF), Chennai, India
| | - Shetanshu Srivastava
- Department of Pediatrics, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Anshula Tayal
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
9
|
Moss RB. Severe Fungal Asthma: A Role for Biologics and Inhaled Antifungals. J Fungi (Basel) 2023; 9:jof9010085. [PMID: 36675906 PMCID: PMC9861760 DOI: 10.3390/jof9010085] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
Allergic asthma has traditionally been treated with inhaled and systemic glucocorticosteroids. A continuum of allergic fungal airways disease associated with Aspergillus fumigatus colonization and/or atopic immune responses that encompasses fungal asthma, severe asthma with fungal sensitization and allergic bronchopulmonary aspergillosis is now recognized along a phenotypic severity spectrum of T2-high immune deviation lung disease. Oral triazoles have shown clinical, anti-inflammatory and microbiologic efficacy in this setting; in the future inhaled antifungals may improve the therapeutic index. Humanized monoclonal antibody biologic agents targeting T2-high disease also show efficacy and promise of improved control in difficult cases. Developments in these areas are highlighted in this overview.
Collapse
Affiliation(s)
- Richard B Moss
- Center of Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University School of Medicine, 770 Welch Road, Suite 350, Palo Alto, CA 94304, USA
| |
Collapse
|
10
|
Steels S, Proesmans M, Bossuyt X, Dupont L, Frans G. Laboratory biomarkers in the diagnosis and follow-up of treatment of allergic bronchopulmonary aspergillosis in cystic fibrosis. Crit Rev Clin Lab Sci 2023; 60:1-24. [PMID: 35968577 DOI: 10.1080/10408363.2022.2101612] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA), a severe inflammatory respiratory disease, is caused by a hypersensitivity reaction to the colonization of the airways with Aspergillus fumigatus. It is most often described in patients with asthma or cystic fibrosis. The diagnosis of ABPA is based on a combination of clinical, radiological, and immunological findings that have been included in different diagnostic criteria over the years. In this paper, we review the biomarkers included in these diagnostic criteria and novel research biomarkers that may be used in the diagnosis and treatment follow-up of ABPA in cystic fibrosis.
Collapse
Affiliation(s)
- Sophie Steels
- Department of Laboratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marijke Proesmans
- Department of Pediatrics, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Xavier Bossuyt
- Department of Laboratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Clinical and Diagnostic Immunology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Lieven Dupont
- Department of Respiratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Glynis Frans
- Department of Laboratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| |
Collapse
|
11
|
Gu L, Li C, Peng X, Lin H, Niu Y, Zheng H, Zhao G, Lin J. Flavopiridol Protects against Fungal Keratitis due to Aspergillus fumigatus by Alleviating Inflammation through the Promotion of Autophagy. ACS Infect Dis 2022; 8:2362-2373. [PMID: 36283079 DOI: 10.1021/acsinfecdis.2c00427] [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: 01/29/2023]
Abstract
Fungal keratitis is a serious infectious keratopathy related to fungal virulence and excessive inflammatory responses. Autophagy exhibits a potent ability to resolve inflammation during fungal infection. This study aimed to investigate the protective function of flavopiridol in Aspergillus fumigatus keratitis and explore its effects on autophagy. In our study, the corneas of the fungal keratitis mouse model were treated with 5 μM flavopiridol. In vitro, RAW 264.7 cells were pretreated with 200 nM flavopiridol before fungal stimulation. A. fumigatus was incubated with flavopiridol, and the antifungal activity of flavopiridol was detected. Our results indicated that flavopiridol treatment notably reduced clinical scores as well as cytokines expression of infected corneas. In infected RAW 264.7 cells, flavopiridol treatment inhibited IL-1β, IL-6, and TNF-α expression but promoted IL-10 expression. Transmission electron microscopy (TEM) images showed that more autolysosomes were present in infected corneas and RAW 264.7 cells after flavopiridol treatment. Flavopiridol treatment notably upregulated the protein expression of LC3, Beclin-1, and Atg-7. 3-Methyladenine (3-MA, an inhibitor of autophagy) pretreatment counteracted the cytokine regulation induced by flavopiridol. Moreover, flavopiridol promoted the phagocytosis of RAW 264.7 cells. Flavopiridol also exhibited antifungal activity by restricting fungal growth and limiting fungal biofilm formation and conidial adhesion. In conclusion, flavopiridol significantly alleviated the inflammation of fungal keratitis by activating autophagy. In addition, flavopiridol promoted the phagocytosis of RAW 264.7 cells and exhibited antifungal function, indicating the potential therapeutic role of flavopiridol in fungal keratitis.
Collapse
Affiliation(s)
- Lingwen Gu
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Cui Li
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Xudong Peng
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Hao Lin
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Yawen Niu
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Hengrui Zheng
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Guiqiu Zhao
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Jing Lin
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| |
Collapse
|
12
|
Francis NZ, Southern KW. Antifungal therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2022; 9:CD002204. [PMID: 36053129 PMCID: PMC9438469 DOI: 10.1002/14651858.cd002204.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is an allergic reaction to colonisation of the lungs with the fungus Aspergillus fumigatus, and affects around 10% of people with cystic fibrosis. ABPA is associated with an accelerated decline in lung function. High doses of corticosteroids are the main treatment for ABPA; although the long-term benefits are not clear, and their many side effects are well-documented. A group of compounds, the azoles, have activity against A fumigatus, and have been proposed as an alternative treatment for ABPA. Of this group, itraconazole is the most active. A separate antifungal compound, amphotericin B, has been used in aerosolised form to treat invasive infection with A fumigatus, and may have potential for the treatment of ABPA. Antifungal therapy for ABPA in cystic fibrosis needs to be evaluated. This is an update of a previously published review. OBJECTIVES The review aimed to test the hypotheses that antifungal interventions for the treatment of ABPA in cystic fibrosis: 1. improve clinical status compared to placebo or standard therapy (no placebo); and 2. do not have unacceptable adverse effects. If benefit was demonstrated, we planned to assess the optimal type, duration, and dose of antifungal therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals, and abstract books of conference proceedings. Date of the most recent search of the Group's Trials Register was 28 September 2021. We searched ongoing trials registries, most recently on 11 March 2022. Earlier, we also approached pharmaceutical companies regarding possible unpublished trials. SELECTION CRITERIA Published or unpublished randomised controlled trials, in which antifungal treatments were compared to either placebo or no treatment, or where different doses of the same treatment were used in the treatment of ABPA in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS The searches identified six trials; none of which met the inclusion criteria for the review. MAIN RESULTS We included no completed randomised controlled trials. There is currently one ongoing trial, which we may find eligible for a future update. AUTHORS' CONCLUSIONS At present, there are no randomised controlled trials that evaluate the use of antifungal therapies for the treatment of ABPA in people with cystic fibrosis, although one trial is currently ongoing. Trials with clear outcome measures are needed to properly evaluate the use of corticosteroids in people with ABPA and cystic fibrosis.
Collapse
Affiliation(s)
- Natalie Z Francis
- Manchester Adult Cystic Fibrosis Centre, University of Manchester, Manchester, UK
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| |
Collapse
|
13
|
Abstract
BACKGROUND This is the second update of previously published reviews in the Cochrane Library (2015, first update 2017). Interleukin-5 (IL-5) is the main cytokine involved in the proliferation, maturation, activation and survival of eosinophils, which cause airway inflammation and are a classic feature of asthma. Studies of monoclonal antibodies targeting IL-5 or its receptor (IL-5R) suggest they reduce asthma exacerbations, improve health-related quality of life (HRQoL) and lung function in appropriately selected patients, justifying their inclusion in the latest guidelines. OBJECTIVES To compare the effects of therapies targeting IL-5 signalling (anti-IL-5 or anti-IL-5Rα) with placebo on exacerbations, health-related quality-of-life (HRQoL) measures and lung function in adults and children with chronic asthma, and specifically in those with eosinophilic asthma refractory to existing treatments. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trials registers, manufacturers' websites, and reference lists of included studies. The most recent search was 7 February 2022. SELECTION CRITERIA We included randomised controlled trials comparing mepolizumab, reslizumab and benralizumab versus placebo in adults and children with asthma. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and analysed outcomes using a random-effects model. We used standard methods expected by Cochrane. MAIN RESULTS Seventeen studies on about 7600 participants met the inclusion criteria. Six used mepolizumab, five used reslizumab, and six used benralizumab. One study using benralizumab was terminated early due to sponsor decision and contributed no data. The studies were predominantly on people with severe eosinophilic asthma, which was similarly but variably defined. One was in children aged 6 to 17 years; nine others included children over 12 years but did not report results by age group separately. We deemed the overall risk of bias to be low, with all studies contributing data of robust methodology. We considered the certainty of the evidence for all comparisons to be high overall using the GRADE scheme, except for intravenous (IV) mepolizumab and subcutaneous (SC) reslizumab because these are not currently licensed delivery routes. The anti-IL-5 treatments assessed reduced rates of 'clinically significant' asthma exacerbation (defined by treatment with systemic corticosteroids for three days or more) by approximately half in participants with severe eosinophilic asthma on standard care (at least medium-dose inhaled corticosteroids (ICS)) with poorly controlled disease (either two or more exacerbations in the preceding year or Asthma Control Questionnaire (ACQ) score of 1.5 or more), except for reslizumab SC. The rate ratios for these effects were 0.45 (95% confidence interval (CI) 0.36 to 0.55; high-certainty evidence) for mepolizumab SC, 0.53 (95% CI 0.44 to 0.64; moderate-certainty evidence) for mepolizumab IV, 0.43 (95% CI 0.33 to 0.55; high-certainty evidence) for reslizumab IV, and 0.59 (95% CI 0.52 to 0.66; high-certainty evidence) for benralizumab SC. Non-eosinophilic participants treated with benralizumab also showed a significant reduction in exacerbation rates, an effect not seen with reslizumab IV, albeit in only one study. No data were available for non-eosinophilic participants treated with mepolizumab. There were improvements in validated HRQoL scores with all anti-IL-5 agents in severe eosinophilic asthma. This met the minimum clinically important difference (MCID) for the broader St. George's Respiratory Questionnaire (SGRQ; 4-point change) for benralizumab only, but the improvement in the ACQ and Asthma Quality of Life Questionnaire (AQLQ), which focus on asthma symptoms, fell short of the MCID (0.5 point change for both ACQ and AQLQ) for all of the interventions. The evidence for an improvement in HRQoL scores in non-eosinophilic participants treated with benralizumab and reslizumab was weak, but the tests for subgroup difference were negative. All anti-IL-5 treatments produced small improvements in mean pre-bronchodilator forced expiratory flow in one second (FEV1) of between 0.08 L and 0.15 L in eosinophilic participants, which may not be sufficient to be detected by patients. There were no excess serious adverse events with any anti-IL-5 treatment; in fact, there was a reduction in such events with benralizumab, likely arising from fewer asthma-related hospital admissions. There was no difference compared to placebo in adverse events leading to discontinuation with mepolizumab or reslizumab, but significantly more discontinued benralizumab than placebo, although the absolute numbers were small (42/2026 (2.1%) benralizumab versus 11/1227 (0.9%) placebo). The implications for efficacy or adverse events are unclear. AUTHORS' CONCLUSIONS Overall this analysis supports the use of anti-IL-5 treatments as an adjunct to standard care in people with severe eosinophilic asthma and poor symptom control. These treatments roughly halve the rate of asthma exacerbations in this population. There is limited evidence for improved HRQoL scores and lung function, which may not meet clinically detectable levels. The studies did not report safety concerns for mepolizumab or reslizumab, or any excess serious adverse events with benralizumab, although there remains a question over adverse events significant enough to prompt discontinuation. Further research is needed on biomarkers for assessing treatment response, optimal duration and long-term effects of treatment, risk of relapse on withdrawal, non-eosinophilic patients, children (particularly under 12 years), comparing anti-IL-5 treatments to each other and, in patients meeting relevant eligibility criteria, to other biological (monoclonal antibody) therapies. For benralizumab, future studies should closely monitor rates of adverse events prompting discontinuation.
Collapse
Affiliation(s)
| | - Amanda Wilson
- School of Nursing and Midwifery, University of Technology Sydney, Sydney, Australia
| | - Stephen Milan
- Health Innovation Campus and Centre for Health Futures, Lancaster University, Lancaster, UK
| | | | - Freda Yang
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Colin Ve Powell
- Department of Emergency Medicine, Sidra Medciine, Doha, Qatar
| |
Collapse
|
14
|
Agarwal R, Muthu V. Prednisolone plus itraconazole in acute-stage allergic bronchopulmonary aspergillosis complicating asthma. Eur Respir J 2021; 59:13993003.02989-2021. [PMID: 34887329 DOI: 10.1183/13993003.02989-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/28/2021] [Indexed: 11/05/2022]
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
| |
Collapse
|
15
|
Havette A, Regard L, Roche N, Burgel PR. Prednisolone plus itraconazole in acute-stage allergic bronchopulmonary aspergillosis complicating asthma: is the benefit worth the risk? Eur Respir J 2021; 59:13993003.02924-2021. [PMID: 34887327 DOI: 10.1183/13993003.02924-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Alice Havette
- Service de Pneumologie, Hôpital Cochin, AP-HP, Paris, France.,These authors equally contributed
| | - Lucile Regard
- Service de Pneumologie, Hôpital Cochin, AP-HP, Paris, France.,Institut Cochin and Université de Paris, INSERM U1016, Paris, France.,These authors equally contributed
| | - Nicolas Roche
- Service de Pneumologie, Hôpital Cochin, AP-HP, Paris, France.,Institut Cochin and Université de Paris, INSERM U1016, Paris, France
| | - Pierre-Régis Burgel
- Service de Pneumologie, Hôpital Cochin, AP-HP, Paris, France .,Institut Cochin and Université de Paris, INSERM U1016, Paris, France
| |
Collapse
|
16
|
Lewington-Gower E, Chan L, Shah A. Review of current and future therapeutics in ABPA. Ther Adv Chronic Dis 2021; 12:20406223211047003. [PMID: 34729149 PMCID: PMC8543630 DOI: 10.1177/20406223211047003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/26/2021] [Indexed: 12/17/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis is an allergic pulmonary condition caused by hypersensitivity to antigens of Aspergillus sp. found most commonly in patients with underlying asthma or cystic fibrosis. Host factors which alter the innate and adaptive immune responses to this abundant airborne fungus contribute to the development of chronic airway inflammation, bronchiectasis, and fibrosis. Traditionally, treatment has focussed on reducing fungal burden and immune response to fungal antigens. However, a significant proportion of patients continue to suffer recurrent exacerbations with progressive lung damage, and the side effect burden of existing treatments is high. New treatments including novel antifungal agents, monoclonal antibodies against aspects of the adaptive immune response as well as targeted immunotherapies may be better tolerated and achieve improved outcomes but have not yet been studied in large-scale randomised control trials.
Collapse
Affiliation(s)
- Elisa Lewington-Gower
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Ley Chan
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Anand Shah
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| |
Collapse
|
17
|
Agarwal R, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Garg M, Aggarwal AN, Chakrabarti A. A randomised trial of prednisolone versus prednisolone and itraconazole in acute-stage allergic bronchopulmonary aspergillosis complicating asthma. Eur Respir J 2021; 59:13993003.01787-2021. [PMID: 34503983 DOI: 10.1183/13993003.01787-2021] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/29/2021] [Indexed: 11/05/2022]
Abstract
Whether a combination of glucocorticoid and antifungal triazole is superior to glucocorticoid alone, in reducing exacerbations, in patients with allergic bronchopulmonary aspergillosis (ABPA) remains unknown. We aimed to compare the efficacy and safety of prednisolone-itraconazole combination versus prednisolone monotherapy in ABPA.We randomised subjects with treatment-naïve acute-stage ABPA complicating asthma to receive either prednisolone alone (four months) or a combination of prednisolone and itraconazole (four and six months, respectively). The primary outcomes were exacerbation rates at 12 months and glucocorticoid-dependent ABPA within 24 months of initiating treatment. The key secondary outcomes were response rates and percentage decline in serum total IgE at six weeks, time to first ABPA exacerbation, and treatment-emergent adverse effects (AE).We randomised 191 subjects to receive either prednisolone (n=94) or prednisolone-itraconazole combination (n=97). The one-year exacerbation rate was 33% and 20.6% in the prednisolone and the prednisolone-itraconazole arms, respectively (p=0.054). None of the participants progressed to glucocorticoid-dependent ABPA. All the subjects experienced a composite response at 6-weeks, along with a decline in serum total IgE (mean decline, 47.6% versus 45.5%). The mean time to first ABPA exacerbation (417 days) was not different between the groups. None of the participants required modification of therapy due to AE.There was a trend towards a decline in ABPA exacerbations at 1-year with the prednisolone-itraconazole combination than prednisolone monotherapy. A three-arm trial comparing itraconazole and prednisolone monotherapies with their combination, preferably in a multicentric design, is required to define the best treatment strategy for acute-stage ABPA.
Collapse
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
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, 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
| |
Collapse
|
18
|
Hong G, Desai S, Moss RB, Eschenhagen P, Quon BS, Schwarz C. Clinician variability in the diagnosis and treatment of aspergillus fumigatus-related conditions in cystic fibrosis: An international survey. J Cyst Fibros 2021; 21:136-142. [PMID: 34332906 DOI: 10.1016/j.jcf.2021.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/07/2021] [Accepted: 07/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The diagnosis and treatment of Aspergillus fumigatus (Af)-related conditions remain a challenge in cystic fibrosis (CF) due to overlapping features of disease and absence of clinical guidelines for Af-related conditions outside of ABPA. OBJECTIVE To investigate the differences of clinical practice in the diagnosis and management of Af-related conditions in CF. METHODS We conducted an international survey to CF clinicians to ascertain the screening, diagnostic, and treatment practices for Af-related conditions in CF. Respondents were grouped into geographical regions and regional comparisons using chi-square tests of independence or Fisher's tests were performed. RESULTS A total of 319 survey responses from 35 countries were analyzed. We observed differences in use and frequency of fungus culture, Aspergillus-specific IgE and IgG, skin prick testing, and pulmonary function testing as screening for Af-related conditions between the geographical regions. ABPA and Aspergillus bronchitis diagnostic criteria selection differed by region; significantly greater proportion of United States (US) and Canadian clinicians were unable to define Aspergillus bronchitis compared to Europe and other regions. Decision to treat ABPA was uniform across regions, but the consideration of Aspergillus bronchitis as a clinical disease warranting therapy differed between regions. The use of glucocorticoid and itraconazole was the first-line treatment of ABPA among clinicians; however, prednisone monotherapy was more common in US and Canada. CONCLUSIONS Significant variability in the diagnosis and management of Aspergillus-related conditions in CF was observed. Future studies are necessary to better harmonize the approach to Af-related disease in CF.
Collapse
Affiliation(s)
- Gina Hong
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sameer Desai
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Richard B Moss
- Center of Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Patience Eschenhagen
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Bradley S Quon
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany; Centre for Heart Lung Innovation, University of British Columbia and St. Paul's Hospital; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Carsten Schwarz
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
19
|
Dhooria S, Sehgal IS, Muthu V, Agarwal R. Treatment of allergic bronchopulmonary aspergillosis: from evidence to practice. Future Microbiol 2021; 15:365-376. [PMID: 32286102 DOI: 10.2217/fmb-2019-0276] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder caused by dysregulated immune responses against Aspergillus fumigatus. The disorder usually complicates the course of patients with asthma and cystic fibrosis. Patients with ABPA most often present with asthma that is poorly controlled despite inhaled corticosteroids and long-acting β2 agonists. The treatment of ABPA is complicated due to the occurrence of recurrent exacerbations and spontaneous remissions. The drugs used for treating ABPA include systemic glucocorticoids, antifungal agents and biologics, each with its own benefits and drawbacks. In this review, we illustrate the treatment pathway for ABPA in different situations, using a case-based approach. In each case, we present the options for treatment based on the available evidence from recent clinical trials.
Collapse
Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| |
Collapse
|
20
|
Wardlaw AJ, Rick EM, Pur Ozyigit L, Scadding A, Gaillard EA, Pashley CH. New Perspectives in the Diagnosis and Management of Allergic Fungal Airway Disease. J Asthma Allergy 2021; 14:557-573. [PMID: 34079294 PMCID: PMC8164695 DOI: 10.2147/jaa.s251709] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/04/2021] [Indexed: 12/23/2022] Open
Abstract
Allergy to airway-colonising, thermotolerant, filamentous fungi represents a distinct eosinophilic endotype of often severe lung disease. This endotype, which particularly affects adult asthma, but also complicates other airway diseases and sometimes occurs de novo, has a heterogeneous presentation ranging from severe eosinophilic asthma to lobar collapse. Its hallmark is lung damage, characterised by fixed airflow obstruction (FAO), bronchiectasis and lung fibrosis. It has a number of monikers including severe asthma with fungal sensitisation (SAFS) and allergic bronchopulmonary aspergillosis/mycosis (ABPA/M), but these exclusive terms constitute only sub-sets of the condition. In order to capture the full extent of the syndrome we prefer the inclusive term allergic fungal airway disease (AFAD), the criteria for which are IgE sensitisation to relevant fungi in association with airway disease. The primary fungus involved is Aspergillus fumigatus, but a number of other thermotolerant species from several genera have been implicated. The unifying mechanism involves germination of inhaled fungal spores in the lung in the context of IgE sensitisation, leading to a persistent and vigorous eosinophilic inflammatory response in association with release of fungal proteases. Most allergenic fungi, including Alternaria and Cladosporium species, are not thermotolerant and cannot germinate in the airways so only act as aeroallergens and do not cause AFAD. Studies of the airway mycobiome have shown that A. fumigatus colonises the normal as much as the asthmatic airway, suggesting it is the tendency to become IgE-sensitised that is the critical triggering factor for AFAD rather than colonisation per se. Treatment is aimed at preventing exacerbations with glucocorticoids and increasingly by the use of anti-T2 biological therapies. Anti-fungal therapy has a limited place in management, but is an effective treatment for fungal bronchitis which complicates AFAD in about 10% of cases.
Collapse
Affiliation(s)
- Andrew J Wardlaw
- Institute for Lung Health, Department of Respiratory Sciences, College of Life Sciences, University of Leicester, and Allergy and Respiratory Medicine Service, NIHR Biomedical Research Centre: Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Eva-Maria Rick
- Institute for Lung Health, Department of Respiratory Sciences, College of Life Sciences, University of Leicester, and Allergy and Respiratory Medicine Service, NIHR Biomedical Research Centre: Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Leyla Pur Ozyigit
- Allergy and Respiratory Services University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alys Scadding
- Allergy and Respiratory Services University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Erol A Gaillard
- Institute for Lung Health, Department of Respiratory Sciences, College of Life Sciences, Department of Paediatrics, NIHR Biomedical Research Centre: Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Catherine H Pashley
- Institute for Lung Health, Department of Respiratory Sciences, College of Life Sciences, University of Leicester, and Allergy and Respiratory Medicine Service, NIHR Biomedical Research Centre: Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| |
Collapse
|
21
|
Sharma P, Ganga RT. Anti-IgE Monoclonal Antibody in Allergic Bronchopulmonary Aspergillosis Not Responding to Systemic Steroids. JOURNAL OF HEALTH AND ALLIED SCIENCES NU 2021. [DOI: 10.1055/s-0041-1726688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractAllergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disorder caused by Aspergillus fumigatus commonly among patients of bronchial asthma. Early diagnosis is the key to successful management and preventing parenchymal destruction. Most of the patients respond well to systemic steroids. In patients not responding to standard treatment, the other treatment options include pulse steroids, antifungals, immunosuppressants, and omalizumab. But exact indication for each of these is not well established. Here we report a 41-year-old ABPA patient who was not responding to systemic steroids became totally asymptomatic with the administration of omalizumab.
Collapse
Affiliation(s)
- Pratibha Sharma
- Department of Microbiology, AIIMS Raipur, Raipur, Chhattisgarh, India
| | - Ranganath T. Ganga
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| |
Collapse
|
22
|
Curran AK, Hava DL. Allergic Diseases Caused by Aspergillus Species in Patients with Cystic Fibrosis. Antibiotics (Basel) 2021; 10:antibiotics10040357. [PMID: 33800658 PMCID: PMC8067098 DOI: 10.3390/antibiotics10040357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/12/2021] [Accepted: 03/24/2021] [Indexed: 01/04/2023] Open
Abstract
Aspergillus spp. are spore forming molds; a subset of which are clinically relevant to humans and can cause significant morbidity and mortality. A. fumigatus causes chronic infection in patients with chronic lung disease such as asthma, chronic obstructive pulmonary disease (COPD) and cystic fibrosis (CF). In patients with CF, A. fumigatus infection can lead to allergic disease, such as allergic bronchopulmonary aspergillosis (ABPA) which is associated with high rates of hospitalizations for acute exacerbations and lower lung function. ABPA results from TH2 immune response to Aspergillus antigens produced during hyphal growth, marked by high levels of IgE and eosinophil activation. Clinically, patients with ABPA experience difficulty breathing; exacerbations of disease and are at high risk for bronchiectasis and lung fibrosis. Oral corticosteroids are used to manage aspects of the inflammatory response and antifungal agents are used to reduce fungal burden and lower the exposure to fungal antigens. As the appreciation for the severity of fungal infections has grown, new therapies have emerged that aim to improve treatment and outcomes for patients with CF.
Collapse
Affiliation(s)
| | - David L. Hava
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
- Correspondence:
| |
Collapse
|
23
|
Agarwal R, Sehgal IS, Dhooria S, Muthu V, Prasad KT, Bal A, Aggarwal AN, Chakrabarti A. Allergic bronchopulmonary aspergillosis. Indian J Med Res 2021; 151:529-549. [PMID: 32719226 PMCID: PMC7602921 DOI: 10.4103/ijmr.ijmr_1187_19] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Kuruswamy T Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| |
Collapse
|
24
|
Abstract
Sporothrix schenckii sensu lato is currently recognized as a species complex with only Sporothrix brasiliensis, Sporothrix schenckii sensu stricto, Sporothrix globosa and Sporothrix pallida identified to cause disease in the cat. Feline sporotrichosis in Asia is mainly reported from Malaysia where a single clonal strain of clinical clade D, Sporothrix schenckii sensu stricto manifesting low susceptibility to major antifungal classes, has been identified as the agent of the disease. Sporothrix globosa has been identified to cause disease from a single cat in Japan while the specific species of agent has not been identified yet for the disease in Thailand. Despite efforts to elucidate and describe the pathogenicity of the agent and the disease it causes, the paucity of data highlights the need for further molecular epidemiological studies to characterize this fungus and the disease it causes in Asia. Its prognosis remains guarded to poor due to issues pertaining to cost, protracted treatment course, zoonotic potential and low susceptibility of some strains to antifungals.
Collapse
Affiliation(s)
- Hock Siew Han
- Vetderm Animal Skin and Ear Specialist Clinic, 9-1 JLN 23/70A, Plaza Crystalville 1, Desa Sri Hartamas, 50480, Kuala Lumpur, Malaysia.
| | - Rui Kano
- Department of Veterinary Dermatology, Nihon University College of Bioresource Sciences, 1866 Kameino, Fujisawa, Kanagawa, 252-0880, Japan
| |
Collapse
|
25
|
Rapeport WG, Ito K, Denning DW. The role of antifungals in the management of patients with severe asthma. Clin Transl Allergy 2020; 10:46. [PMID: 33292524 PMCID: PMC7646070 DOI: 10.1186/s13601-020-00353-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/19/2020] [Indexed: 12/26/2022] Open
Abstract
In patients with asthma, the inhalation of elevated amounts of fungal spores and hyphae may precipitate the onset of asthma or worsen control to the extent of being life-threatening. Sensitisation to fungi, especially Aspergillus fumigatus, is found in 15% to 48% of asthmatics in secondary care and is linked to worse asthma control, hospitalisation, bronchiectasis and fixed airflow obstruction, irrespective of whether allergic bronchopulmonary aspergillosis (ABPA) is diagnosed. ABPA represents a florid response to the presence of Aspergillus spp. but up to 70% of patients with severe asthma exhibit sensitisation to different fungi without meeting the diagnostic criteria for ABPA. The presence of persistent endobronchial colonisation with fungi, especially A. fumigatus, is linked to significantly higher rates of radiological abnormalities, lower post-bronchodilator FEV1 and significantly less reversibility to short acting bronchodilators. The therapeutic benefit for antifungal intervention in severe asthma is based on the assumption that reductions in airway fungal burden may result in improvements in asthma control, lung function and symptoms (especially cough). This contention is supported by several prospective studies which demonstrate the effectiveness of antifungals for the treatment of ABPA. Significantly, these studies confirm lower toxicity of treatment with azoles versus high dose oral corticosteroid dosing regimens for ABPA. Here we review recent evidence for the role of fungi in the progression of severe asthma and provide recommendations for the use of antifungal agents in patients with severe asthma, airways fungal infection (mycosis) and fungal colonisation. Documenting fungal airways colonisation and sensitisation in those with severe asthma opens up alternative therapy options of antifungal therapy, which may be particularly valuable in low resource settings.
Collapse
Affiliation(s)
- W Garth Rapeport
- Airways Disease, National Heart and Lung Institute, Imperial College, London, SW3 6LY, UK.
| | - Kazuhiro Ito
- Airways Disease, National Heart and Lung Institute, Imperial College, London, SW3 6LY, UK
- Pulmocide Ltd., 44 Southampton Building, London, WC2A 1AP, UK
| | - David W Denning
- Manchester Fungal Infection Group (MFIG), Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| |
Collapse
|
26
|
Kono Y, To M, Tsuzuki R, Yamawaki S, Soeda S, To Y. Pulmonary emphysema is associated with fungal sensitization in asthma. J Thorac Dis 2020; 12:5879-5886. [PMID: 33209420 PMCID: PMC7656412 DOI: 10.21037/jtd-20-995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Fungal sensitization is a risk factor for severe asthma. Colonization in the lower respiratory tract is one of the forms of fungal exposure, and it is related to fungal sensitization. Pulmonary emphysema was recently reported to be an underlying disease of fungal colonization. The aim of study was to evaluate the prevalence of pulmonary emphysema in asthmatic patients with and without fungal sensitization. Methods We enrolled 108 patients with allergic asthma and divided them into the patients sensitized to Aspergillus and/or Candida (n=56) and those not sensitized to both Aspergillus and Candida (n=52). The presence of pulmonary emphysema on chest CT was evaluated retrospectively. Results The frequency of pulmonary emphysema was significantly higher in the patients sensitized to Aspergillus and/or Candida compared to the patients not sensitized to both fungi (P=0.0040). The frequency of pulmonary emphysema was also significantly higher in the patients sensitized to either Aspergillus or Candida compared to the patient not sensitized to the fungi (P=0.0398 and P=0.0198, respectively). A multivariate logistic regression analysis demonstrated that the presence of pulmonary emphysema was independently associated with the sensitization to Aspergillus and/or Candida (OR 7.84, 95% CI: 1.20–51.10). Conclusions Pulmonary emphysema is associated with sensitization to Aspergillus and/or Candida.
Collapse
Affiliation(s)
- Yuta Kono
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Masako To
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Ryuta Tsuzuki
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Satoshi Yamawaki
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Seiko Soeda
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Yasuo To
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| |
Collapse
|
27
|
Omalizumab Is an Effective Intervention in Severe Asthma with Fungal Sensitization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3428-3433.e1. [PMID: 32561499 DOI: 10.1016/j.jaip.2020.05.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Severe asthma with fungal sensitization (SAFS) and allergic bronchopulmonary aspergillosis (ABPA) are important complications of severe asthma. The evidence for treating them with omalizumab is limited. OBJECTIVE To determine the effectiveness of treatment with omalizumab in patients with severe allergic asthma comparing those with and without evidence of fungal sensitization using data recorded in the Australian Xolair Registry. METHODS Data from 205 patients who received omalizumab and recorded in the Australian Xolair Registry were analyzed to determine change in the Juniper 5-item Asthma Control Questionnaire (ACQ-5) score, exacerbation frequency, and oral corticosteroid dose over a 24-month period of omalizumab treatment. Patients were grouped into cohorts on the basis of fungal sensitization, and an analysis of improvement in outcomes between baseline and 24 months was conducted within each group. A further subgroup analysis of patients with ABPA was also conducted. RESULTS Patients with SAFS (n = 62), including those with ABPA (ASAFS), were as likely to demonstrate significant improvements in ACQ-5 score and exacerbations and reduced regular oral corticosteroid dose over 24 months as those with severe asthma without sensitization to fungi (n = 156). After adjusting for age, sex, body mass index, smoking history, and baseline FEV1%, the effects still remained. A subgroup analysis of 11 patients with ABPA similarly demonstrated a significant improvement on omalizumab. CONCLUSIONS Omalizumab is an effective therapy in ASAFS, leading to sustained improvements in symptoms and exacerbations for 24 months. The benefit for ABPA is less clear because of the small sample size.
Collapse
|
28
|
Pulmonary Aspergillosis: What the Generalist Needs to Know. Am J Med 2020; 133:668-674. [PMID: 32240631 DOI: 10.1016/j.amjmed.2020.02.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022]
Abstract
Aspergillus spp. is a ubiquitous mold found commonly in our environment that can cause a spectrum of pulmonary disorders, ranging from a hypersensitivity reaction to an acutely invasive disease with significant mortality. Allergic bronchopulmonary aspergillosis results from airway hypersensitivity from aspergillus colonization almost exclusively in patients with asthma and cystic fibrosis. Chronic pulmonary aspergillosis typically presents in immunocompetent patients with underlying lung pathology. Treatment is primarily with antifungal agents; however, other measures such as surgical resection may be necessary. Invasive pulmonary aspergillosis is a severe infection in immunocompromised patients and is characterized by invasion of pulmonary vasculature by the Aspergillus hyphae. Recent advances in the diagnosis and management of invasive pulmonary aspergillosis include emerging risk factors such as critically ill patients, and those with chronic obstructive pulmonary disease and liver disease. In addition, noninvasive biomarkers have made it easier to suspect and diagnose invasive pulmonary aspergillosis. There are more effective and better-tolerated antifungal agents that have improved patient outcomes. This review introduces the spectrum of pulmonary aspergillosis geared toward generalists, including disease manifestations, most recent diagnostic criteria, and first-line treatment options. Involving a multidisciplinary team is vital to the early diagnosis and management of these diseases.
Collapse
|
29
|
Kozlova Y, Frolova E, Uchevatkina A, Filippova L, Aak O, Burygina E, Taraskina A, Vasilyeva N, Klimko N. Diagnostic markers of allergic bronchopulmonary aspergillosis in patients with severe asthma. Mycoses 2020; 63:596-603. [PMID: 32246509 DOI: 10.1111/myc.13083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/10/2020] [Accepted: 03/21/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Allergic bronchopulmonary aspergillosis (ABPA) is a lung disease in patients with asthma or cystic fibrosis (CF) caused by chronic allergic inflammation to Aspergillus spp. antigens. The role of different immunological mediators in the formation of chronic allergic inflammation in patients with ABPA is not sufficiently explored. OBJECTIVES This study aimed to investigate serum levels of thymic stromal lymphopoietin (TSLP), thymus and activated chemokine (TARC) as well as IL-8 in patients with ABPA, and to evaluate their diagnostic and monitoring value in the disease. PATIENTS/METHODS Prospective study included 21 patients with ABPA, 25 patients with severe asthma with fungal sensitisation (SAFS), 37 patients with severe asthma without fungal sensitisation (SAwFS), and 16 healthy people. In patients with ABPA, the serum levels of biomarkers were determined at baseline and after 12 weeks of itraconazole therapy. Serum levels of total IgE, Aspergillus-fumigatus-specific IgE, TSLP, TARC, IL-8 were analysed by enzyme-linked immunosorbent assay. RESULTS In patients with ABPA we established significantly higher serum levels of TARC, IL-8, total IgE, Aspergillus-fumigatus-specific IgE and peripheral blood eosinophil counts, compared to patients with SAwFS. There were no differences in TSLP levels between the examined groups of patients. Serum TARC levels were positively correlated to serum total IgE levels, A fumigatus-specific IgE levels and peripheral blood eosinophil counts and also negatively correlated to lung function (FEV1 ). Longitudinally, serum levels TARC, total IgE and peripheral blood eosinophil counts significant decreased after treatment of ABPA. CONCLUSION Thymus and activated chemokine is a useful test in diagnosing and monitoring response to the antifungal treatment of patients with ABPA.
Collapse
Affiliation(s)
- Yana Kozlova
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Ekaterina Frolova
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Aleksandra Uchevatkina
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Larisa Filippova
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Oleg Aak
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Ekaterina Burygina
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Anastasiya Taraskina
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Natalia Vasilyeva
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Nikolay Klimko
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
| |
Collapse
|
30
|
Sehgal IS, Dhooria S, Muthu V, Prasad KT, Agarwal R. An overview of the available treatments for chronic cavitary pulmonary aspergillosis. Expert Rev Respir Med 2020; 14:715-727. [PMID: 32249630 DOI: 10.1080/17476348.2020.1750956] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Chronic pulmonary aspergillosis (CPA) is a chronic lung infection caused by Aspergillus fumigatus, that complicates structural lung diseases. Of the different types of CPA, chronic cavitary pulmonary aspergillosis (CCPA) is the most common form. The mainstay of treatment of CCPA is oral triazoles. However, many gaps exist in clinical decision-making about the agent of choice, the duration, and the assessment of treatment response. AREAS COVERED We discuss the approach to diagnosis and treatment of CCPA. We have searched the PubMed and EmBase databases (from inception till 31 October 2019) to identify studies describing the use of anti-fungal agents in CCPA. EXPERT OPINION Treatment for CCPA should be initiated with oral itraconazole for at least six months. In case of poor response or intolerance to itraconazole, voriconazole should be considered. Intravenous agents, including amphotericin B and echinocandins, may be used in those with either treatment failure or those who are intolerant to oral antifungal agents. Posaconazole and isavuconazole may be used as salvage therapy due to a better pharmacokinetic/pharmacodynamic profile of the former and reduced drug-drug interactions with the latter.
Collapse
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
| | - Valliappan Muthu
- 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
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
| |
Collapse
|
31
|
Fukushima C, Matsuse H, Obase Y, Fukahori S, Tsuchida T, Kawano T, Kohno S, Mukae H. Liposomal Amphotericin B Fosters the Corticosteroids' Anti-inflammatory Effect on Murine Allergic Bronchopulmonary Aspergillosis Model Airways. Inflammation 2020; 42:2065-2071. [PMID: 31396817 DOI: 10.1007/s10753-019-01069-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Fungus is an antigen for bronchial asthma causing allergic bronchopulmonary mycosis (ABPM). As a therapy other than corticosteroids, itraconazole (ITCZ) is known to suppress the allergic inflammation induced by Aspergillus fumigatus (Af). However, the efficacy of liposomal amphotericin B (LAMB) with/without corticosteroid on ABPM is unknown. Mice sensitized to Dermatophagoides farinae (Df) allergen were intranasally infected with Af (DfAf group). After the infection, corticosteroid (dexamethasone (Dex)) was administered for 5 days (DfAf/Dex group). The effects of ITCZ or LAMB with/without Dex were also evaluated. Pathologically, Dex and LAMB combination treatment decreased the allergic inflammation evidently. The bronchoalveolar lavage fluid (BALF) concentrations of IL-5, IL-13, and MIP-2 were significantly elevated in DfAf mice compared with control mice (p < 0.05, each). In DfAf mice, ITCZ and LAMB significantly decreased the elevation of MIP-2 (p < 0.05 vs the DfAf group). The addition of both Dex and LAMB suppressed the MIP-2 elevation in DfAf mice (p < 0.05 vs the Df/Af/Dex/LAMB group), but the addition of Dex and ITCZ did not (DfAf/Dex/ITCZ group). None of Dex, ITCZ, or LAMB decreased pulmonary IL-13 concentration. It was suggested that combination of antifungal drugs and corticosteroid enhanced the suppressing effect of airway inflammations. This finding will give a hope for the treatment of severe fungus-related asthma.
Collapse
Affiliation(s)
- Chizu Fukushima
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroto Matsuse
- Division of Respiratory Medicine, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Susumu Fukahori
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tomoko Tsuchida
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuya Kawano
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shigeru Kohno
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| |
Collapse
|
32
|
Otu AA, Langridge P, Denning DW. An evaluation of nebulised amphotericin B deoxycholate (Fungizone ® ) for treatment of pulmonary aspergillosis in the UK National Aspergillosis Centre. Mycoses 2020; 62:1049-1055. [PMID: 31479538 DOI: 10.1111/myc.12996] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/21/2019] [Accepted: 08/27/2019] [Indexed: 12/12/2022]
Abstract
Antifungal treatment options for allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS) are largely limited to itraconazole based on the outcome of randomised controlled trials. It is unclear if nebulised amphotericin B deoxycholate (Fungizone® ) is a viable therapeutic option. We evaluated the safety and efficacy of nebulised Fungizone® in the long-term treatment of various forms of pulmonary aspergillosis. We assessed the records of 177 patients with various forms of pulmonary aspergillosis attending the National Aspergillosis Centre in Manchester who had received Fungizone® . Patients first received a challenge test with nebulised Fungizone® in hospital with spirometry pre/post-Fungizone® and nebulised salbutamol given pre-Fungizone® . Tolerability and changes in Aspergillus IgE, Aspergillus IgG and total IgE were evaluated. Sixty-six per cent (117/177) were able to tolerate the test dose of Fungizone® and in all cases, the reason for discontinuation of the first test dose was worsening breathlessness. Twenty six (21%) stopped therapy within 4-6 weeks, and the commonest reason cited for discontinuation of therapy was increased breathlessness, hoarseness and cough. Eighteen (10.2%) patients continued the Fungizone® for >3 months of which 5 (27.8%) recorded an improvement in total IgE, Aspergillus-specific IgE and Aspergillus IgG. Eleven had ABPA, four had SAFS, two had Aspergillus bronchitis and one had Aspergillus sensitisation with cavitating nodules. Among these 18 patients, sputum fungal culture results went from positive to negative in five patients, became positive in one patient, remained positive in three patients, and remained negative in seven patients. Nebulised Fungizone® appears to be a poorly tolerated treatment for pulmonary Aspergillosis with high dropout rates. There appears to be both clinical and serological benefits following sustained treatment with nebulised Fungizone® in some patients.
Collapse
Affiliation(s)
- Akaninyene A Otu
- The National Aspergillosis Centre, 2nd Floor Education and Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,College of Medical Sciences, University of Calabar, Calabar, Nigeria
| | - Philip Langridge
- The National Aspergillosis Centre, 2nd Floor Education and Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - David W Denning
- The National Aspergillosis Centre, 2nd Floor Education and Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Manchester, UK
| |
Collapse
|
33
|
Hava DL, Tan L, Johnson P, Curran AK, Perry J, Kramer S, Kane K, Bedwell P, Layton G, Swann C, Henderson D, Khan N, Connor L, McKenzie L, Singh D, Roach J. A phase 1/1b study of PUR1900, an inhaled formulation of itraconazole, in healthy volunteers and asthmatics to study safety, tolerability and pharmacokinetics. Br J Clin Pharmacol 2020; 86:723-733. [PMID: 31696544 DOI: 10.1111/bcp.14166] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 09/30/2019] [Accepted: 10/17/2019] [Indexed: 01/21/2023] Open
Abstract
AIMS Oral itraconazole has variable pharmacokinetics and risks of adverse events associated with high plasma exposure. An inhalation formulation of itraconazole (PUR1900) is being developed to treat allergic bronchopulmonary aspergillosis, an allergic inflammatory disease occurring in asthmatics and patients with cystic fibrosis. METHODS A 3-part, open-label Phase 1 study was conducted to evaluate safety, tolerability and pharmacokinetics of PUR1900. Healthy volunteers (n = 5-6/cohort) received either single (Part 1) or multiple (Part 2) ascending doses of PUR1900 for up to 14 days. In Part 3 stable, adult asthmatics received a single dose of 20 mg PUR1900 or 200 mg of oral Sporanox (itraconazole oral solution) in a 2-period randomized cross-over design. Itraconazole plasma and sputum concentrations were evaluated. RESULTS None of the adverse events considered as at least possibly related to study treatment were moderate or severe, and none were classed as serious. The most common was the infrequent occurrence of mild cough. Itraconazole plasma exposure increased with increasing doses of PUR1900. After 14 days, PUR1900 resulted in plasma exposure (area under the concentration-time curve up to 24 h) 106- to 400-fold lower across doses tested (10-35 mg) than steady-state exposure reported for oral Sporanox 200 mg. In asthmatics, PUR1900 geometric mean maximum sputum concentrations were 70-fold higher and geometric mean plasma concentrations were 66-fold lower than with oral Sporanox. CONCLUSION PUR1900 was safe and well-tolerated under the study conditions. Compared to oral dosing, PUR1900 achieved higher lung and lower plasma exposure. The pharmacokinetic profile of PUR1900 suggests the potential to improve upon the efficacy and safety profile observed with oral itraconazole.
Collapse
Affiliation(s)
| | - Lisa Tan
- Lisa Tan Pharma Consulting, Kingston, Cambridge, UK
| | | | | | | | | | | | | | | | | | | | - Naimat Khan
- Medicines Evaluation Unit, The Langley Building, Wythenshawe Hospital, Wythenshawe, UK, England
| | - Lucy Connor
- Medicines Evaluation Unit, The Langley Building, Wythenshawe Hospital, Wythenshawe, UK, England
| | | | - Dave Singh
- Medicines Evaluation Unit, The Langley Building, Wythenshawe Hospital, Wythenshawe, UK, England.,University of Manchester, Manchester University NHS Hospital Trust, Manchester, UK
| | | |
Collapse
|
34
|
Sunman B, Ademhan Tural D, Ozsezen B, Emiralioglu N, Yalcin E, Özçelik U. Current Approach in the Diagnosis and Management of Allergic Bronchopulmonary Aspergillosis in Children With Cystic Fibrosis. Front Pediatr 2020; 8:582964. [PMID: 33194914 PMCID: PMC7606581 DOI: 10.3389/fped.2020.582964] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder characterized by a hypersensitivity reaction to Aspergillus fumigatus, and almost always seen in patients with cystic fibrosis (CF) and asthma. Fungal hyphae leads to an ongoing inflammation in the airways that may result in bronchiectasis, fibrosis, and eventually loss of lung function. Despite the fact that ABPA is thought to be more prevalent in CF than in asthma, the literature on ABPA in CF is more limited. The diagnosis is challenging and may be delayed because it is made based on a combination of clinical features, and radiologic and immunologic findings. With clinical deterioration of a patient with CF, ABPA is important to be kept in mind because clinical manifestations mimic pulmonary exacerbations of CF. Early diagnosis and appropriate treatment are important in preventing complications related to ABPA. Treatment modalities involve the use of anti-inflammatory agents to suppress the immune hyperreactivity and the use of antifungal agents to reduce fungal burden. Recently, in an effort to treat refractory patients or to reduce adverse effects of steroids, other treatment options such as monoclonal antibodies have started to be used. Intensive research of these new agents in the treatment of children is being conducted to address insufficient data.
Collapse
Affiliation(s)
- Birce Sunman
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dilber Ademhan Tural
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Beste Ozsezen
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nagehan Emiralioglu
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ebru Yalcin
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Uğur Özçelik
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
35
|
Mirsadraee M, Dehghan S, Ghaffari S, Mirsadraee N. Long-term effect of antifungal therapy for the treatment of severe resistant asthma: an active comparator clinical trial. Curr Med Mycol 2019; 5:1-7. [PMID: 32104737 PMCID: PMC7034786 DOI: 10.18502/cmm.5.4.1986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose: Itraconazole therapy has been reported to control asthma in severe therapy-resistant asthma with fungal sensitization. The aim of this study was to investigate the impact of anti-fungal therapy on the treatment of severe asthma, irrespective of sensitization. Materials and Methods: This active comparator clinical trial was performed on 110 therapy-resistant asthmatic patients who were randomly assigned into two groups of case and control. The patients in the case group were administered 200 mg itraconazole twice a day and the control group received 10 mg prednisolone after breakfast for 4 months. The asthma control test (ACT) which was used as a marker for the global evaluation of treatment effectiveness (GETE) was applied as the primary endpoint parameter. Cough, dyspnea, and sleep disturbance were measured on a scale of 1-4, with 1 representing no symptom and 4 indicating severe exhausting disturbance. Results: Based on the obtained results, 71% of the itraconazole group demonstrated a marked improvement in the GETE score after a four-month treatment. Itraconazole was able to suppress clinical symptoms, including cough, dyspnea, and night symptoms, and their physical exam was indicative of normalization in 60% of the patients. On the other hand, the patients in the parallel group "prednisolone" were only able to control dyspnea. The ACT score represented a notable improvement with itraconazole (mean: 14 before the trial and >20 after the trial) and spirometry parameters underwent a considerable change from obstructive pattern to normal. Furthermore, adverse effects were only detected in 6% of itraconazole users. Conclusion: The results of this clinical trial indicted the effectiveness of antifungal therapy for the control of the clinical condition of a subgroup of patients with severe steroid-refractory asthma.
Collapse
Affiliation(s)
- Majid Mirsadraee
- Internist and Pulmonologist, Professor, Islamic Azad University, Mashhad Branch, Mashhad, Iran
| | - Sanaz Dehghan
- Innovative Research Center, Faculty of Medicine, Islamic Azad University, Mashhad Branch, Mashhad, Iran
| | - Shadi Ghaffari
- MSc in Biology, Research Department, Kavosh High School, Mashhad, Iran
| | - Niloofar Mirsadraee
- MSc in Cell and Molecular Biology, Innovative Research Center, Faculty of Medicine, Islamic Azad University, Mashhad Branch, Mashhad, Iran
| |
Collapse
|
36
|
A unique case of hydropneumothorax in allergic bronchopulmonary aspergillosis. Med Mycol Case Rep 2019; 25:29-31. [PMID: 31338287 PMCID: PMC6626827 DOI: 10.1016/j.mmcr.2019.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 11/23/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is an immunologically mediated disease characterized by a hypersensitivity reaction to fungal colonization by Aspergillus. Hydropneumothoraces and bronchopleural fistulae are rare occurrences in patients with ABPA. However, the diagnosis of ABPA is important to consider, as it is easily treatable with specific therapy. We report an unusual case of a patient with ABPA who presented to us with hydropneumothorax with bronchopleural fistula.
Collapse
|
37
|
Mochimaru T, Fukunaga K, Ueda S, Kuroda A, Watanabe R, Chubachi S, Betsuyaku T. Allergic bronchopulmonary aspergillosis in succession to chronic eosinophilic pneumonia. Allergol Int 2019; 68:370-371. [PMID: 30670338 DOI: 10.1016/j.alit.2018.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 12/04/2018] [Accepted: 12/13/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- Takao Mochimaru
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan.
| | - Koichi Fukunaga
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Soichiro Ueda
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Aoi Kuroda
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Risa Watanabe
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shotaro Chubachi
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tomoko Betsuyaku
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
38
|
Upham JW, Chung LP. Optimising treatment for severe asthma. Med J Aust 2019; 209:S22-S27. [PMID: 30453869 DOI: 10.5694/mja18.00175] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/30/2018] [Indexed: 11/17/2022]
Abstract
The treatment landscape in severe asthma is changing rapidly, with multiple new therapies emerging that promise to transform patient outcomes. In a patient who is not responding to conventional therapy with inhaled corticosteroids and long-acting β2-agonists, it is important to first consider if the diagnosis of asthma is correct and, second, to reflect on whether readily modifiable factors are contributing to poor asthma control. In selected patients it may be appropriate to consider a modified n-of-1 trial of add-on therapies such as long-acting anti-muscarinic agents, leukotriene blockers, theophylline or low dose macrolide antibiotics. A number of monoclonal antibodies are now available that target the molecular pathways that contribute to asthma pathogenesis, and more such agents are likely to emerge in the near future. These biologicals can be transformative in selected patients, markedly reducing the frequency of asthma exacerbations, and allowing many patients to reduce or eliminate their use of long term oral corticosteroids. If the promise of personalised treatment is to be fully realised, it is important that better methods are developed to target these new and expensive treatments to patients most likely to respond. The ultimate goal of inducing remission or cure of asthma is still some distance away.
Collapse
Affiliation(s)
- John W Upham
- Diamantina Institute, University of Queensland, Brisbane, QLD
| | | |
Collapse
|
39
|
Hill AT, Sullivan AL, Chalmers JD, De Soyza A, Elborn SJ, Floto AR, Grillo L, Gruffydd-Jones K, Harvey A, Haworth CS, Hiscocks E, Hurst JR, Johnson C, Kelleher PW, Bedi P, Payne K, Saleh H, Screaton NJ, Smith M, Tunney M, Whitters D, Wilson R, Loebinger MR. British Thoracic Society Guideline for bronchiectasis in adults. Thorax 2019; 74:1-69. [PMID: 30545985 DOI: 10.1136/thoraxjnl-2018-212463] [Citation(s) in RCA: 225] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Adam T Hill
- Respiratory Medicine, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Anita L Sullivan
- Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust (Queen Elizabeth Hospital), Birmingham, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital, Dundee, UK
| | - Anthony De Soyza
- Institute of Cellular Medicine, NIHR Biomedical Research Centre for Aging and Freeman Hospital Adult Bronchiectasis service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Stuart J Elborn
- Royal Brompton Hospital and Imperial College London, and Queens University Belfast
| | - Andres R Floto
- Department of Medicine, University of Cambridge, Cambridge UK.,Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge UK
| | | | | | - Alex Harvey
- Department of Clinical Sciences, Brunel University London, London, UK
| | - Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge UK
| | | | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | | | - Peter W Kelleher
- Centre for Immunology and Vaccinology, Chelsea &Westminster Hospital Campus, Department of Medicine, Imperial College London.,Host Defence Unit, Department of Respiratory Medicine, Royal Brompton Hospital and Harefield NHS Foundation Trust, London.,Chest & Allergy Clinic St Mary's Hospital, Imperial College Healthcare NHS Trust
| | - Pallavi Bedi
- University of Edinburgh MRC Centre for Inflammation Research, Edinburgh, UK
| | | | | | | | - Maeve Smith
- University of Alberta, Edmonton, Alberta, Canada
| | - Michael Tunney
- School of Pharmacy, Queens University Belfast, Belfast, UK
| | | | - Robert Wilson
- Host Defence Unit, Department of Respiratory Medicine, Royal Brompton Hospital and Harefield NHS Foundation Trust, London
| | - Michael R Loebinger
- Host Defence Unit, Department of Respiratory Medicine, Royal Brompton Hospital and Harefield NHS Foundation Trust, London
| |
Collapse
|
40
|
Agarwal R, Sehgal IS, Dhooria S, Aggarwal AN. Challenging cases in fungal asthma. Med Mycol 2019; 57:S110-S117. [PMID: 30816974 DOI: 10.1093/mmy/myy063] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/23/2018] [Accepted: 07/12/2018] [Indexed: 02/06/2023] Open
Abstract
Fungal asthma broadly encompasses the presence of fungal sensitization or fungal allergy in patients with asthma. The clinical presentation of fungal asthma can vary from fungal-sensitized asthma at one end to allergic bronchopulmonary mycosis at the other end of the spectrum. Here we present five cases that illustrate some of the most challenging aspects of the diagnosis and management of fungal asthma. The cases are aimed at elucidating complex clinical presentations in fungal asthma such as allergic bronchopulmonary mycosis presenting with normal immunoglobulin E (IgE) values, the role of several different fungi in causing allergic mycosis, newer treatments like omalizumab (and mepolizumab), and a complication of long-standing allergic bronchopulmonary aspergillosis, namely, chronic pulmonary aspergillosis.
Collapse
Affiliation(s)
- Ritesh Agarwal
- Professor Department of Pulmonary Medicine Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | | | - Ashutosh N Aggarwal
- Professor Department of Pulmonary Medicine Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
41
|
Menon DP, Patel NM. 65-Year-Old Woman With a Wheeze. Mayo Clin Proc 2019; 94:e39-e44. [PMID: 30713049 DOI: 10.1016/j.mayocp.2018.04.035] [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: 02/16/2018] [Revised: 04/16/2018] [Accepted: 04/30/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Divya Padmanabhan Menon
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Neal M Patel
- Advisor to resident and Consultant in Critical Care Medicine and Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL.
| |
Collapse
|
42
|
Mohammed AO, Alameeri A, Moloney E. Late-onset allergic bronchopulmonary aspergillosis (ABPA). QJM 2019; 112:209-211. [PMID: 30496509 DOI: 10.1093/qjmed/hcy279] [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: 08/19/2018] [Revised: 11/12/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- A O Mohammed
- Department of Respiratory Medicine, Tallaght Hospital, Dublin, Ireland
| | - A Alameeri
- Department of Respiratory Medicine, Tallaght Hospital, Dublin, Ireland
| | - E Moloney
- Department of Respiratory Medicine, Tallaght Hospital, Dublin, Ireland
| |
Collapse
|
43
|
Wu J, Wu Y, Zhu Z. Pulmonary infection caused by Nocardia cyriacigeorgica in a patient with allergic bronchopulmonary aspergillosis: A case report. Medicine (Baltimore) 2018; 97:e13023. [PMID: 30412142 PMCID: PMC6221653 DOI: 10.1097/md.0000000000013023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
RATIONALE Nocardia species is known as conditional pathogenic bacteria. Among Nocardia species, pulmonary infection caused by Nocardia cyriacigeorgica associated with Aspergillus fumigatus complex lung disease is rarely reported. PATIENT CONCERNS A 55-year-old female with a history of productive cough with recurrent expectoration for 20 years presented with increasing cough for 12 months. The patient presented complaining of respiratory symptoms including increasing cough with yellow phlegm, poor appetite, and generalized fatigue for a week prior to admission. DIAGNOSES Nocardia cyriacigeorgica pneumonia was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and 16S rRNA gene sequencing. INTERVENTIONS Combined treatments (trimethoprim-sulfamethoxazole and meropenem) were administered after identification of N cyriacigeorgica. OUTCOMES The respiratory symptoms of the patient had improved both clinically and radiologically after 4 weeks of antibacterial therapy. LESSONS Early precise diagnosis and prompt combined therapy are of vital importance in severe Nocardia pulmonary infection.
Collapse
|
44
|
Agarwal R, Dhooria S, Sehgal IS, Aggarwal AN, Garg M, Saikia B, Chakrabarti A. A randomised trial of voriconazole and prednisolone monotherapy in acute-stage allergic bronchopulmonary aspergillosis complicating asthma. Eur Respir J 2018; 52:13993003.01159-2018. [PMID: 30049743 DOI: 10.1183/13993003.01159-2018] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/07/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Ritesh Agarwal
- Dept of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Dept of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul S Sehgal
- Dept of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N Aggarwal
- Dept of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mandeep Garg
- Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Biman Saikia
- Dept of Immunopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- Dept of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
45
|
The spectrum of pulmonary aspergillosis. Respir Med 2018; 141:121-131. [PMID: 30053957 DOI: 10.1016/j.rmed.2018.06.029] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/26/2018] [Accepted: 06/29/2018] [Indexed: 11/24/2022]
Abstract
Notable progress has been made in the past years in the classification, diagnosis and treatment of pulmonary aspergillosis. New criteria were proposed by the Working Group of the International Society for Human and Animal Mycology (ISHAM) for the diagnosis of allergic bronchopulmonary aspergillosis (ABPA). The latest classification of chronic pulmonary aspergillosis (CPA) suggested by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) has become widely accepted among clinicians. Subacute invasive pulmonary aspergillosis is now considered a type of CPA, yet it is still diagnosed and treated similarly to invasive pulmonary aspergillosis (IPA). Isavuconazole, an extended-spectrum triazole, has recently been approved by the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the treatment of IPA. The most recent Infectious Diseases Society of America (IDSA) guidelines strongly recommend reducing mold exposure to patients at high risk for pulmonary aspergillosis. The excessive relapse rate following discontinuation of therapy remains a common reality to all forms of this semi-continuous spectrum of diseases. This highlights the need to continuously reassess patients and individualize therapy accordingly. Thus far, the duration of therapy and the frequency of follow-up have to be well characterized.
Collapse
|
46
|
Li E, Tsai C, Maskatia ZK, Kakkar E, Porter P, Rossen RD, Perusich S, Knight JM, Kheradmand F, Corry DB. Benefits of antifungal therapy in asthma patients with airway mycosis: A retrospective cohort analysis. Immun Inflamm Dis 2018; 6:264-275. [PMID: 29575717 PMCID: PMC5946149 DOI: 10.1002/iid3.215] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Fungal airway infection (airway mycosis) is increasingly recognized as a cause of asthma and related disorders. However, prior controlled studies of patients treated with antifungal antibiotics have produced conflicting results. Our objective is to measure the effect of antifungal therapy in moderate to severe adult asthmatics with positive fungal sputum cultures in a single center referral-based academic practice. METHODS We retrospectively evaluated 41 patients with asthma and culture-proven airway mycosis treated with either terbinafine, fluconazole, itraconazole, voriconazole, or posaconazole for 4 to >12 weeks together with standard bronchodilator and anti-inflammatory agents. Asthma control (1 = very poorly controlled; 2 = not well controlled; and 3 = well controlled), peak expiratory flow rates (PEFR), serum total IgE, and absolute blood eosinophil counts before and after antifungal therapy were assessed. In comparison, we also studied nine patients with airway mycosis and moderate to severe asthma who received standard therapy but no antifungals. RESULTS Treatment with azole-based and allylamine antifungals was associated with improved asthma control (mean change in asthma control 1.72-2.25; p = 0.004), increased PEFR (69.4% predicted to 79.3% predicted, p = 0.0011) and markedly reduced serum IgE levels (1,075 kU/L to 463 kU/L, p = 0.0005) and blood eosinophil counts (Mean absolute count 530-275, p = 0.0095). Reduction in symptoms, medication use, and relapse rates decreased as duration of therapy increased. Asthmatics on standard therapy who did not receive antifungals showed no improvement in asthma symptoms or PEFR. Antifungals were usually well tolerated, but discontinuation (12.2%) and relapse (50%) rates were relatively high. CONCLUSION Antifungals help control symptoms in a subset of asthmatics with culture-proven airway mycosis. Additional randomized clinical trials are warranted to extend and validate these findings.
Collapse
Affiliation(s)
- Evan Li
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
| | - Chu‐Lin Tsai
- Department of Emergency MedicineNational Taiwan University HospitalTaipeiTaiwan
| | | | - Ekta Kakkar
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
| | - Paul Porter
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTexasUSA
| | - Roger D. Rossen
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTexasUSA
| | - Sarah Perusich
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
- Department of Biology of Inflammation CenterBaylor College of MedicineHoustonTexasUSA
| | - John M. Knight
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTexasUSA
| | - Farrah Kheradmand
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTexasUSA
- Department of Biology of Inflammation CenterBaylor College of MedicineHoustonTexasUSA
- Michael E. DeBakey VA Center for Translational Research on Inflammatory DiseasesHoustonTexasUSA
| | - David B. Corry
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTexasUSA
- Department of Biology of Inflammation CenterBaylor College of MedicineHoustonTexasUSA
- Michael E. DeBakey VA Center for Translational Research on Inflammatory DiseasesHoustonTexasUSA
| |
Collapse
|
47
|
Li XY, Zhang YQ, Xu G, Li SH, Li H. miR-124/MCP-1 signaling pathway modulates the protective effect of itraconazole on acute kidney injury in a mouse model of disseminated candidiasis. Int J Mol Med 2018; 41:3468-3476. [PMID: 29568906 DOI: 10.3892/ijmm.2018.3564] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 01/12/2018] [Indexed: 11/06/2022] Open
Abstract
Previous studies have indicated that monocyte chemoattractant protein-1 (MCP‑1), also referred to as C‑C motif chemokine ligand 2, has a significant role in the pathogenesis of sepsis, however, how microRNAs (miRs) contribute to this process remains to be fully elucidated. In the present study, using a mouse model of disseminated candidiasis, the renoprotective effect of itraconazole (ITR) and adenovirus‑delivered miR‑124 was investigated. The mice were treated with ITR (50 mg/kg) or transfected with miR‑124 mimics via tail‑vein injection 7 days prior to Candida albicans infection. The survival outcome was monitored following candidiasis‑induced sepsis with ITR or miR‑124 mimics treatment. The levels of pro‑inflammatory cytokines, including tumor necrosis factor‑α (TNF‑α), interleukin‑1β (IL‑1β) and IL‑6, were determined using enzyme‑linked immunosorbent assays. The mRNA and protein levels were assayed using reverse transcription-quantitative polymerase chain reaction and western blot analyses, respectively. The results showed that ITR and miR‑124 mimics improved the survival outcome in candidiasis‑induced septic mice. The findings also indicated a significant downregulation in the serum levels of TNF‑α, IL‑1β and IL‑6 in the septic mice treated with ITR or miR‑124 mimics. Of note, ITR treatment significantly increased the expression of miR‑124 and decreased the levels of MCP‑1 in the kidneys of the septic mice. It was also shown that the overexpression of miR‑124 reduced the expression of MCP‑1 and attenuated candidiasis‑induced acute kidney injury (AKI) in septic mice. Transfection with miR‑124 mimics was equivalent to ITR in reducing the excessive inflammatory response and renal lesions in septic mice. These results provided evidence supporting the use of miR‑124 mimics as a therapeutic approach for attenuating candidiasis-induced AKI.
Collapse
Affiliation(s)
- Xiao-Yue Li
- Department of Critical Care Medicine, The Second Affiliated Hospital of Guilin Medical University, Guilin, Guanxi 541199, P.R. China
| | - Yu-Qi Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Guilin Medical University, Guilin, Guanxi 541199, P.R. China
| | - Gang Xu
- Department of Geriatrics, Guangzhou First People's Hospital, Guangzhou, Guangdong 510000, P.R. China
| | - Shao-Hong Li
- Department of Emergency, TungWah Affiliated Hospital of Sun Yat‑sen University, Dongguan, Guangdong 523220, P.R. China
| | - Heng Li
- Department of Cardiovascular Medicine, TungWah Affiliated Hospital of Sun Yat‑sen University, Dongguan, Guangdong 523220, P.R. China
| |
Collapse
|
48
|
Abstract
Eosinophils are the prominent cells in asthma, allergic bronchopulmonary mycosis (ABPMs), and fungal-sensitization-associated asthma, but their roles in the immunopathology of these disorders are not well understood. Moreover, the immunological mechanisms underlying the molecular direct effector interactions between fungi and eosinophils are rare and not fully known. Here, we provide an overview of eosinophil contributions to allergic asthma and ABPMs. We also revise the major general mechanisms of fungal recognition by eosinophils and consider past and recent advances in our understanding of the molecular mechanisms associated with eosinophil innate effector responses to different fungal species relevant to ABPMs (Alternaria alternata, Candida albicans, and Aspergillus fumigatus). We further examine and speculate about the therapeutic relevance of these findings in fungus-associated allergic pulmonary diseases.
Collapse
Affiliation(s)
- Rodrigo T Figueiredo
- Institute of Biomedical Sciences/Unit of Xerem, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Josiane S Neves
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| |
Collapse
|
49
|
Zervas E, Samitas K, Papaioannou AI, Bakakos P, Loukides S, Gaga M. An algorithmic approach for the treatment of severe uncontrolled asthma. ERJ Open Res 2018. [PMID: 29531957 PMCID: PMC5838355 DOI: 10.1183/23120541.00125-2017] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
A small subgroup of patients with asthma suffers from severe disease that is either partially controlled or uncontrolled despite intensive, guideline-based treatment. These patients have significantly impaired quality of life and although they constitute <5% of all asthma patients, they are responsible for more than half of asthma-related healthcare costs. Here, we review a definition for severe asthma and present all therapeutic options currently available for these severe asthma patients. Moreover, we suggest a specific algorithmic treatment approach for the management of severe, difficult-to-treat asthma based on specific phenotype characteristics and biomarkers. The diagnosis and management of severe asthma requires specialised experience, time and effort to comprehend the needs and expectations of each individual patient and incorporate those as well as his/her specific phenotype characteristics into the management planning. Although some new treatment options are currently available for these patients, there is still a need for further research into severe asthma and yet more treatment options. Stepwise approach for the treatment of severe asthmahttp://ow.ly/rLPl30i0TyZ
Collapse
Affiliation(s)
- Eleftherios Zervas
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Konstantinos Samitas
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | | | - Petros Bakakos
- 1st Respiratory Medicine Dept, Athens Chest Hospital "Sotiria", University of Athens, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Dept, Attikon Hospital, University of Athens, Athens, Greece
| | - Mina Gaga
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| |
Collapse
|
50
|
Devilliers H, Turcu A, Vernier N, Muller G, Bielefeld P, Bonniaud P, Besancenot JF. [Hyper-IgE in internal medicine]. Rev Med Interne 2018; 39:332-338. [PMID: 29397233 DOI: 10.1016/j.revmed.2017.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/12/2017] [Accepted: 12/28/2017] [Indexed: 01/14/2023]
Abstract
Hyper-IgE may be found under many pathological conditions. The role of IgE is essentially associated with the occurrence of allergic manifestations, which may be accompanied by an increase of their serum levels. Elevation of total IgE has also been reported in association with certain rare genetic immune deficiencies called hyper-IgE syndromes. Other circumstances such as infectious diseases, tumors or autoimmune diseases may also be accompanied by an excessive synthesis of IgE. Considering the diversity of these situations, discussion of the prognostic value of total IgE is useful to the internist.
Collapse
Affiliation(s)
- H Devilliers
- Service de médecine interne et maladies systémiques, CHU François-Mitterrand, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - A Turcu
- Service de médecine interne et maladies systémiques, CHU François-Mitterrand, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France.
| | - N Vernier
- Service de médecine interne et maladies systémiques, CHU François-Mitterrand, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - G Muller
- Service de médecine interne et maladies systémiques, CHU François-Mitterrand, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - P Bielefeld
- Service de médecine interne et maladies systémiques, CHU François-Mitterrand, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - P Bonniaud
- Service de pneumologie, CHU François-Mitterrand, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - J-F Besancenot
- Service de médecine interne et maladies systémiques, CHU François-Mitterrand, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| |
Collapse
|