Allergic bronchopulmonary aspergillosis in asthma

Allergic bronchopulmonary aspergillosis as an initial manifestation of cystic fibrosis: Diagnostic and therapeutic implications in the era of CFTR modulators

Allergic bronchopulmonary aspergillosis (ABPA) results from complex hypersensitivity reactions to Aspergillus fumigatus, which often occur in patients with asthma, cystic fibrosis (CF), or CF transmembrane conductance regulator (CFTR)-related disorders. Genetic predisposition, particularly variants of the CFTR gene, probably plays a significant role in the development of ABPA. We present the case of a 20-year-old male with ABPA and bronchiectasis that was initially misdiagnosed as a result of normal sweat chloride values and negative first-level genetic testing results. Comprehensive CFTR gene sequencing revealed 2 pathogenic variants, R347H and D1152H, which together with the clinical phenotype and functional tests, supported the diagnosis of CF. Treatment with elexacaftor/tezacaftor/ivacaftor resulted in significant clinical and functional improvement, including a marked decrease in total IgE levels, suggesting a potential role for CFTR modulators in controlling ABPA. This case illustrates the evolving understanding of CF as a spectrum of disorders in which CFTR dysfunction may manifest subtly and variably, necessitating a high index of suspicion and a comprehensive diagnostic approach to ensure timely treatment in the era of highly effective CFTR modulators.

Prevalence of Aspergillus Sensitization and Allergic Bronchopulmonary Aspergillosis in Adults With Bronchial Asthma: A Systematic Review of Global Data

BACKGROUND

The prevalence of allergic bronchopulmonary aspergillosis (ABPA) in asthmatic patients remains unclear and is likely different across geographic locales.

OBJECTIVE

To systematically review the literature for estimating the prevalence of Aspergillus sensitization (AS) and ABPA in adults with bronchial asthma.

METHODS

We searched the PubMed and Embase databases for studies reporting the prevalence of AS or ABPA in at least 50 asthmatic subjects. The primary outcome was to assess the prevalence of ABPA. The secondary outcome was to evaluate the prevalence of AS in asthma and that of ABPA in asthma with AS. We pooled the prevalence estimates using a random-effects model and examined the factors influencing the prevalence using multivariate meta-regression.

RESULTS

Of the 11,801 records retrieved, 86 studies with 25,770 asthmatic subjects met the inclusion criteria. Most of the studies were from tertiary care centers. The pooled prevalence of ABPA in asthma (47 studies; 9822 asthmatic subjects) was 11.3% (95% CI, 8.7-14.2). The pooled prevalence of AS in asthma (73 studies; 23,003 asthmatic subjects) was 25.1% (95% CI, 20.5-30.0), whereas the prevalence of ABPA in AS (36 studies; 2954 asthmatic subjects) was 37.0% (95% CI, 27.9-46.6). Multivariate meta-regression identified studies published from India (odds ratio, 1.11; 95% CI, 1.01-1.23) as the only factor associated with higher ABPA prevalence. There was presence of significant statistical heterogeneity and publication bias.

CONCLUSIONS

We found a high prevalence of ABPA in adult asthmatic subjects, underscoring the need for screening for ABPA in all asthmatic subjects seeking tertiary care.

Omalizumab in Allergic Bronchopulmonary Aspergillosis: A Systematic Review and Meta-Analysis

BACKGROUND

An unmet clinical need exists in the management of treatment-refractory allergic bronchopulmonary aspergillosis (ABPA). Omalizumab has shown promising effects in case series and cohort studies; however, evidence to support its routine clinical use is lacking.

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the clinical effectiveness and safety of omalizumab in patients with ABPA.

METHODS

We conducted a systematic search across standard databases using specific key words until May 13, 2021. We performed a meta-analysis to compare the effectiveness (exacerbations, oral corticosteroid [OCS] use, lung function, and patient-reported asthma control) and safety of pre- and post-omalizumab treatment. Subgroup analyses were performed for treatment duration and underlying disease.

RESULTS

In total, 49 studies (n = 267) were included in the qualitative synthesis and 14 case series (n = 186) in the quantitative meta-analysis. Omalizumab treatment significantly reduced the annualized exacerbation rate compared with pretreatment (mean difference, -2.09 [95% CI, -3.07 to -1.11]; P < .01). There was a reduction in OCS use (risk difference, 0.65 [95% CI, 0.46-0.84]; P < .01), an increase in termination of OCS use (risk difference, 0.53 [95% CI, 0.24-0.82]; P < .01), and a reduction in OCS dose (milligrams per day) (mean difference, -14.62 [95% CI, -19.86 to -9.39]; P < .01) in ABPA patients receiving omalizumab. Omalizumab improved FEV₁ % predicted by 11.9% (95% CI, 8.2-15.6; P < .01) and asthma control, and was well-tolerated.

CONCLUSIONS

Omalizumab treatment reduced exacerbations and OCS use, improved lung function and asthma control in patients with ABPA, and was well-tolerated. The results highlight the potential role of omalizumab in the treatment of ABPA.

Macrophage Lysosomal Alkalinization Drives Invasive Aspergillosis in a Mouse Cystic Fibrosis Model of Airway Transplantation

Cystic fibrosis (CF) lung transplant recipients (LTRs) exhibit a disproportionately high rate of life-threatening invasive aspergillosis (IA). Loss of the cystic fibrosis transmembrane conductance regulator (CFTR-/-) in macrophages (mφs) has been associated with lyosomal alkalinization. We hypothesize that this alkalinization would persist in the iron-laden post-transplant microenvironment increasing the risk of IA. To investigate our hypothesis, we developed a murine CF orthotopic tracheal transplant (OTT) model. Iron levels were detected by immunofluorescence staining and colorimetric assays. Aspergillus fumigatus (Af) invasion was evaluated by Grocott methenamine silver staining. Phagocytosis and killing of Af conidia were examined by flow cytometry and confocal microscopy. pH and lysosomal acidification were measured by LysoSensorTM and LysotrackerTM, respectively. Af was more invasive in the CF airway transplant recipient compared to the WT recipient (p < 0.05). CFTR-/- mφs were alkaline at baseline, a characteristic that was increased with iron-overload. These CFTR-/- mφs were unable to phagocytose and kill Af conidia (p < 0.001). Poly(lactic-co-glycolic acid) (PLGA) nanoparticles acidified lysosomes, restoring the CFTR-/- mφs’ ability to clear conidia. Our results suggest that CFTR-/- mφs’ alkalinization interacts with the iron-loaded transplant microenvironment, decreasing the CF-mφs’ ability to kill Af conidia, which may explain the increased risk of IA. Therapeutic pH modulation after transplantation could decrease the risk of IA.

Environmental Factors and the Risk of Developing Type 1 Diabetes-Old Disease and New Data

Simple Summary

Despite many studies, the risk factors of type 1 diabetes (T1DM) in children and adolescents are still not fully understood and remain a big challenge. Therefore, an extensive online search for scientific research on factors related to diabetes has been performed for the identification of new factors of unexplained etiology. A better understanding of the role of viral, bacterial, and yeast-like fungi infections related to the risk of T1DM in children and adolescents and the identification of new risk factors, especially those spread by the droplet route, is of great importance for people and families with diabetes.

Abstract

The incidence of type 1 diabetes (T1D) is increasing worldwide. The onset of T1D usually occurs in childhood and is caused by the selective destruction of insulin-producing pancreatic islet cells (β-cells) by autoreactive T cells, leading to insulin deficiency. Despite advanced research and enormous progress in medicine, the causes of T1D are still not fully understood. Therefore, an extensive online search for scientific research on environmental factors associated with diabetes and the identification of new factors of unexplained etiology has been carried out using the PubMed, Cochrane, and Embase databases. The search results were limited to the past 11 years of research and discovered 143 manuscripts published between 2011 and 2022. Additionally, 21 manuscripts from between 2000 and 2010 and 3 manuscripts from 1974 to 2000 were referenced for historical reference as the first studies showcasing a certain phenomenon or mechanism. More and more scientists are inclined to believe that environmental factors are responsible for the increased incidence of diabetes. Research results show that higher T1D incidence is associated with vitamin D deficiency, a colder climate, and pollution of the environment, as well as the influence of viral, bacterial, and yeast-like fungi infections. The key viral infections affecting the risk of developing T1DM are rubella virus, mumps virus, Coxsackie virus, cytomegalovirus, and enterovirus. Since 2020, i.e., from the beginning of the COVID-19 pandemic, more and more studies have been looking for a link between Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and diabetes development. A better understanding of the role of viral, bacterial, and yeast-like fungi infections related to the risk of T1DM in children and adolescents and the identification of new risk factors, especially those spread by the droplet route, is of great importance for people and families with diabetes.

Characterising the allergic profile of children with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is a genetic condition that affects multiple organ systems. Allergic bronchopulmonary aspergillosis (ABPA) is a well-recognised problem but other allergic conditions are less well documented in CF.

OBJECTIVE

To characterise the allergic profile of a cohort of children with CF, with a focus on those with ABPA.

METHODS

A cohort of children with CF were interviewed and retrospective data were collected regarding their allergic histories and other relevant clinical features.

RESULTS

The cohort included 37 children with median age of 9 years (interquartile range: 6-12). There was a history of ≥1 allergic condition(s) in 28/37 children (76%). The most common allergic condition was allergic rhinitis (AR) in 21/37 (57%) and 16 of these 21 children (76%) had another allergic condition. All children with ABPA (8) had another allergic condition. In some children ABPA exacerbations appeared to be seasonal, suggesting possible cross-sensitisation between Aspergillus fumigatus and aeroallergens associated with seasonal AR. Allergic conditions were also common in children with Pseudomonas aeruginosa infection.

Host Lung Environment Limits Aspergillus fumigatus Germination through an SskA-Dependent Signaling Response

Aspergillus fumigatus isolates display significant heterogeneity in growth, virulence, pathology, and inflammatory potential in multiple murine models of invasive aspergillosis. Previous studies have linked the initial germination of a fungal isolate in the airways to the inflammatory and pathological potential, but the mechanism(s) regulating A. fumigatus germination in the airways is unresolved. To explore the genetic basis for divergent germination phenotypes, we utilized a serial passaging strategy in which we cultured a slow germinating strain (AF293) in a murine-lung-based medium for multiple generations. Through this serial passaging approach, a strain emerged with an increased germination rate that induces more inflammation than the parental strain (herein named LH-EVOL for lung homogenate evolved). We identified a potential loss-of-function allele of Afu5g08390 (sskA) in the LH-EVOL strain. The LH-EVOL strain had a decreased ability to induce the SakA-dependent stress pathway, similar to AF293 ΔsskA and CEA10. In support of the whole-genome variant analyses, sskA, sakA, or mpkC loss-of-function strains in the AF293 parental strain increased germination both in vitro and in vivo. Since the airway surface liquid of the lungs contains low glucose levels, the relationship of low glucose concentration on germination of these mutant AF293 strains was examined; interestingly, in low glucose conditions, the sakA pathway mutants exhibited an enhanced germination rate. In conclusion, A. fumigatus germination in the airways is regulated by SskA through the SakA mitogen-activated protein kinase (MAPK) pathway and drives enhanced disease initiation and inflammation in the lungs.

IMPORTANCEAspergillus fumigatus is an important human fungal pathogen particularly in immunocompromised individuals. Initiation of growth by A. fumigatus in the lung is important for its pathogenicity in murine models. However, our understanding of what regulates fungal germination in the lung environment is lacking. Through a serial passage experiment using lung-based medium, we identified a new strain of A. fumigatus that has increased germination potential and inflammation in the lungs. Using this serially passaged strain, we found it had a decreased ability to mediate signaling through the osmotic stress response pathway. This finding was confirmed using genetic null mutants demonstrating that the osmotic stress response pathway is critical for regulating growth in the murine lungs. Our results contribute to the understanding of A. fumigatus adaptation and growth in the host lung environment.

Mepolizumab and dupilumab as a replacement to systemic glucocorticoids for the treatment of Chronic Eosinophilic Pneumonia and Allergic Bronchopulmonary Aspergillosis - Case series, Almoosa specialist hospital

In this case series, we present four patients who had asthma and blood eosinophilia. Two patients were diagnosed with Chronic Eosinophilic Pneumonia (CEP) and the other two with Allergic Bronchopulmonary Aspergillosis (ABPA). Laboratory findings revealed profound peripheral eosinophilia with abnormal chest radiography (alveolar shadows, segmental atelectasis, and cystic changes). Initial improvement (clinical, laboratory, and radiological) occurred with traditional asthma therapy, including systemic corticosteroids. The patients did not tolerate corticosteroid therapy because of weight gain, uncontrolled diabetes, bone fractures, and psychological adverse effects. Mepolizumab (administered to two CEP cases and one ABPA case) and Dupilumab (administered to one ABPA case) were initiated as steroid-sparing agents, resulting in successful therapy without relapse or adverse effects. Mepolizumab, and Interleukin-5 (IL-5) antagonist, targets diseases mediated by eosinophil activity and proliferation. Dupilumab blocks the Interleukin-4/Interleukin-13 pathway and suppresses Type 2 inflammation, including Immunoglobulin E (IgE). Dupilumab resulted in up to 70% drop in total IgE levels from baseline and reduced eosinophil-mediated lung inflammation, despite the presence of normal or increased blood eosinophil counts.

Molecular allergology approach to allergic asthma

Allergic asthma is a frequently encountered and well described asthma phenotype. However, its precise mechanisms are less known. The tools for targeted selection of patients for an optimal response to intervention (prevention or treatment) are also lacking. Here we explore the potential of the molecular allergology approach to achieve a better understanding of allergic asthma mechanisms, a precise diagnosis and an optimal management of these patients.

Comprehensive transcriptome analysis of peripheral blood unravels key lncRNAs implicated in ABPA and asthma

Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity lung disease caused by a fungus known as Aspergillus fumigatus. It complicates and aggravates asthma. Despite their potential associations, the underlying mechanisms of asthma developing into ABPA remain obscure. Here we performed an integrative transcriptome analysis based on three types of human peripheral blood, which derived from ABPA patients, asthmatic patients and health controls, aiming to identify crucial lncRNAs implicated in ABPA and asthma. Initially, a high-confidence dataset of lncRNAs was identified using a stringent filtering pipeline. A comparative mutational analysis revealed no significant difference among these samples. Differential expression analysis disclosed several immune-related mRNAs and lncRNAs differentially expressed in ABPA and asthma. For each disease, three sub-networks were established using differential network analysis. Many key lncRNAs implicated in ABPA and asthma were identified, respectively, i.e., AL139423.1-201, AC106028.4-201, HNRNPUL1-210, PUF60-218 and SREBF1-208. Our analysis indicated that these lncRNAs exhibits in the loss-of-function networks, and the expression of which were repressed in the occurrences of both diseases, implying their important roles in the immune-related processes in response to the occurrence of both diseases. Above all, our analysis proposed a new point of view to explore the relationship between ABPA and asthma, which might provide new clues to unveil the pathogenic mechanisms for both diseases.

Fungal asthma among Ugandan adult asthmatics

Fungal sensitization is associated with poor asthma control. We aimed to determine the prevalence and factors associated with fungal asthma among Ugandan adults. Individuals aged ≥18 years with a new diagnosis of asthma in the last 12 months participating in the African Severe Asthma Program constituted the study population. Skin prick test results, clinical and demographic data were retrieved from the database, and serum Aspergillus fumigatus specific antibodies and total IgE were measured in stored blood. We enrolled 374 patients, median (IQR) age 34 (25-45) years, 286 (76.5%) females and 286 (76.5%) with severe asthma. Prevalence of Aspergillus fumigatus sensitization was 42.0% (95% CI: 37.1-47.0%), allergic bronchopulmonary aspergillosis (ABPA) 3.2% (1.8-5.5%), severe asthma with fungal sensitization (SAFS) 16% (12.7-20.1%) and allergic bronchopulmonary mycosis (ABPM) 2.9% (1.7-5.2%). Older age (55-64 years) (crude odds ratio (cOR) = 2.6), sensitization to at least one allergen (cOR = 9.38) and hypertension (cOR = 1.99) were significantly associated with Aspergillus sensitization, whereas tertiary education level (cOR = 0.29), severe depression (cOR = 0.15) and strong emotions (cOR = 0.47) were not. High occupational exposure to Aspergillus (cOR = 4.26) and contact with moulds (cOR = 14.28) were significantly associated with ABPA. Palpitations (cOR = 5.54), uncontrolled asthma (cOR = 3.54), eczema/dermatitis (cOR = 3.07), poor lung function (cOR = 2.11) and frequent exacerbations (cOR = 1.01) were significantly associated with SAFS. Eczema/dermatitis (cOR = 1.55) was significantly associated with ABPM, but cold weather trigger (cOR = 0.24) was not. Fungal asthma is a significant problem among Ugandans with asthma and should be particularly considered in individuals who remain uncontrolled despite optimal standard of care for asthma, as it is responsive to available and affordable oral antifungal therapy.

LAY SUMMARY

This study showed that fungal asthma is a significant problem among Ugandans with asthma with a high prevalence. Fungal asthma should be considered in patients with uncontrolled asthma despite receiving optimal standard of care. This is the first modern attempt to define these endotypes of asthma in Africa.

Role of circulating microRNA-132 in allergic bronchopulmonary aspergillosis: A case-control study

Allergic bronchopulmonary aspergillosis (ABPA) is an allergic respiratory disease. In the current study, we aimed to evaluate the roles of miRNA-21 and miRNA132 as biomarkers in the diagnosis of ABPA. A total of 30 controls, 30 allergic asthmatic patients, 30 severe asthma with fungal sensitization (SAFS) patients, and 30 ABPA patients were included. Real-time polymerase chain reaction was used to quantify the level of miRNAs expression. The expression level of miRNA-21 was significantly higher in allergic asthmatic, SAFS, and ABPA patients in comparison with controls (p < 0.001). However, no significant difference was detected in the expression level of miRNA-21 among the different patient groups (p > 0.05). The ABPA patients had significantly higher levels of miRNA-132 expression compared to controls, allergic asthmatic patients, and SAFS patients (p < 0.001), but there was a non-significant difference between controls and allergic asthmatic patients (p = 0.09). At a cut-off of 1.52, the sensitivity of miRNA-132 expression was 93.3% and the specificity was 100% different ABPA from healthy controls. At a cut-off of 6.5, miRNA-132 expression was found to reliably differentiate between ABPA and SAFS, with a sensitivity of 86.7% and a specificity of 80%. In ABPA patients, miRNA-132 expression positively correlation with the levels of serum IL-5 (r = 0.91, p < 0.001). miRNA-132 has a role in ABPA detection and distinguishing ABPA from allergic asthma and SAFS. These preliminary data from case-control study need further studies to confirm its finding.

Proteomic Analysis of Serum Differentially Expressed Proteins Between Allergic Bronchopulmonary Aspergillosis and Asthma

BACKGROUND

Allergic bronchopulmonary aspergillosis (ABPA) constantly develops in asthmatics, which has not been fully investigated.

OBJECTIVES

This study aimed to investigate serum differentially expressed proteins (DEPs) between ABPA and asthma using the new approach isobaric tags by relative and absolute quantitation (iTRAQ).

METHODS

Each 16 serum samples from ABPA or asthmatic subjects were pooled and screened using iTRAQ. After bioinformatic analysis, five candidate DEPs were validated in the enlarged serum samples from additional 21 ABPA, 31 asthmatic and 20 healthy subjects using ELISA. A receiver operating characteristic (ROC) curve was used to estimate the diagnostic power of carnosine dipeptidase 1 (CNDP1).

RESULTS

A total of 29 DEPs were screened out between ABPA and asthmatic groups. Over half of them were enriched in proteolysis and regulation of protein metabolic process. Further verification showed serum levels of immunoglobulin heavy constant gamma 1, α-1-acid glycoprotein 1, corticosteroid-binding globulin and vitronectin were neither differentially altered between ABPA and asthma nor consistent with the proteomic analysis. Only serum CNDP1 was significantly decreased in ABPA patients, compared with asthmatics and healthy controls (P < 0.01 and P < 0.05). The ROC analysis determined 10.73 ng/mL as the cutoff value of CNDP1, which could distinguish ABPA among asthmatics (AUC 0.770, 95%CI 0.632-0.875, P < 0.001).

CONCLUSIONS

This study firstly identified serological DEPs between ABPA and asthma using the new technique iTRAQ. Serum CNDP1 might assist the differential diagnosis of ABPA from asthma and serve as a new pathogenetic factor in fungal colonization and sensitization.

Diagnostic markers of allergic bronchopulmonary aspergillosis in patients with severe asthma

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.

Clinical characteristics of allergic bronchopulmonary aspergillosis

BACKGROUND

Allergic bronchopulmonary aspergillosis (ABPA) is an allergic pulmonary disease caused by a hypersensitivity reaction to Aspergillus colony in the airways. Due to the diversity of disease manifestations and physicians' incomplete knowledge of ABPA, patients with ABPA are often misdiagnosed and given poor prognosis.

OBJECTIVES

To investigate the clinical characteristics, treatment and prognosis status among patients with ABPA.

METHODS

We retrospectively analyzed 75 patients diagnosed as ABPA in Zhongshan Hospital, Fudan University between October 2008 and June 2018.

RESULTS

Among 75 patients, 28% had asthma as the predisposing condition and 69% suffered from misdiagnosis before ABPA diagnosis was made, among which 21% were misdiagnosed as tuberculosis. About 34% of patients had eosinophil count below 500 cells/μL and 25% had total serum IgE level <1000 IU/mL. Nearly half of patients did not meet the diagnostic criteria of ABPA and all the patients who overlapped with invasive pulmonary aspergillosis (IPA) did not meet the diagnostic criteria of standard ABPA. Patients who did not fully meet the diagnostic criteria were more likely treated with inhaled corticosteroids (ICS) and antibiotics, but more difficult to attain response and remission and easier to develop advanced ABPA.

CONCLUSIONS

This study demonstrates an unsatisfactory situation of diagnosis, treatment and prognosis of ABPA, including a high misdiagnosis rate, uncertainty in the diagnosis of ABPA, lack of standardization in treatment and relatively poor prognosis.

Asthma in Children and Adults-What Are the Differences and What Can They Tell us About Asthma?

Asthma varies considerably across the life course. Childhood asthma is known for its overall high prevalence with a male predominance prior to puberty, common remission, and rare mortality. Adult asthma is known for its female predominance, uncommon remission, and unusual mortality. Both childhood and adult asthma have variable presentations, which are described herein. Childhood asthma severity is associated with duration of asthma symptoms, medication use, lung function, low socioeconomic status, racial/ethnic minorities, and a neutrophilic phenotype. Adult asthma severity is associated with increased IgE, elevated FeNO, eosinophilia, obesity, smoking, and low socioeconomic status. Adult onset disease is associated with more respiratory symptoms and asthma medication use despite higher prebronchodilator FEV1/FVC. There is less quiescent disease in adult onset asthma and it appears to be less stable than childhood-onset disease with more relapses and less remissions.

Component-Resolved Diagnosis in Allergic Rhinitis and Asthma

BACKGROUND

Allergic rhinitis and asthma are highly prevalent chronic inflammatory diseases leading to restrictions in the patient's quality of life and high costs for healthcare systems. Both diseases are associated with the presence of specific IgE (sIgE) against aeroallergens. This review aims to examine the importance of molecular allergy diagnostics in the assessment and management of these disorders.

CONTENT

The "U-shaped" approach, proposed by the European Academy of Allergy and Clinical Immunology, combines conventional allergy diagnostics with the benefits of component-resolved diagnosis (CRD) and offers important additional information regarding the patient's sensitization pattern, especially in complex clinical cases such as polysensitization or idiopathic reactions, thus avoiding overuse of in vitro and in vivo IgE diagnostics. CRD may help the clinician to identify the cause of an allergy and, in the case of complex polysensitization, uncover possible cross-reactivity. Polysensitization, especially to inhalant allergens, is associated with the clinical appearance of asthma and allergic rhinitis; important risk factors for the latter are the major allergens Fel d 1 and Can f 1. Importantly, information on molecular sensitization patterns significantly influences the choice of specific immunotherapy and reduces its overprescription.

CONCLUSION

At present, allergy diagnostics largely rely on clinical history, physical examination, and in vivo IgE testing. However, in vitro diagnostics including CRD are currently finding their way into the clinical routine and can offer additional information on the patient's sensitization profile and treatment responsiveness.

A case of allergic bronchopulmonary aspergillosis successfully treated with mepolizumab

Background

Allergic bronchopulmonary aspergillosis (ABPA) is an allergic pulmonary disease comprising a complex hypersensitivity reaction to Aspergillus fumigatus. Clinical features of ABPA are wheezing, mucoid impaction, and pulmonary infiltrates. Oral corticosteroids and anti-fungal agents are standard therapy for ABPA, but long-term use of systemic corticosteroids often causes serious side effects.

Case presentation

A 64-year-old woman was diagnosed with ABPA based on a history of bronchial asthma (from 40 years of age), elevated total IgE, the presence of serum precipitating antibodies and elevated specific IgE antibody to A. fumigatus, and pulmonary infiltration. Bronchoscopy showed eosinophilic mucoid impaction. Systemic corticosteroid therapy was initiated, and her symptoms disappeared. Peripheral eosinophilia and pulmonary infiltration recurred five months after cessation of corticosteroid treatment. Systemic corticosteroids were re-initiated and itraconazole was added as an anti-fungal agent. The patient was free of corticosteroids, aside from treatment with a short course of systemic corticosteroids for asthma exacerbation, and clinically stable with itraconazole and asthma treatments for 3 years. In 2017, she experienced significant deterioration. Laboratory examination revealed marked eosinophilia (3017/μL) and a chest computed tomography (CT) scan demonstrated pulmonary infiltration in the left upper lobe and mucoid impaction in both lower lobes. The patient was treated with high-dose inhaled corticosteroid/long-acting beta-agonist, a long-acting muscarinic antagonist, a leukotriene receptor antagonist, and theophylline; spirometry revealed a forced expiratory volume in 1 s (FEV₁) of 1.01 L. An uncontrolled asthma state was indicated by an Asthma Control Test (ACT) score of 18. Mepolizumab, 100 mg every 4 weeks, was initiated for the treatment of severe bronchial asthma with ABPA exacerbation. Bronchial asthma symptoms dramatically improved, and ACT score increased to 24, by 4 weeks after mepolizumab treatment. Peripheral eosinophil count decreased to 174/μL. Spirometry revealed improvement of lung function (FEV₁: 1.28 L). A chest CT scan demonstrated the disappearance of pulmonary infiltration and mucoid impaction.

Conclusions

To our knowledge, this is the first case of ABPA to be treated with mepolizumab. Dramatic improvements were observed in symptoms, lung function, peripheral eosinophil counts, and chest images. Mepolizumab could serve as an alternative treatment with the potential to provide a systemic corticosteroid-sparing effect.