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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.
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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
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Dalip D, Scott BJ, Giddings S, Rampersad FS, Jaggernauth S. Allergic Bronchopulmonary Aspergillosis in Trinidad: A Case Report. Cureus 2021; 13:e19527. [PMID: 34804747 PMCID: PMC8592292 DOI: 10.7759/cureus.19527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2021] [Indexed: 11/14/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is an immunologically mediated disease resulting from a hypersensitivity reaction to Aspergillus fumigatus. ABPA is identified by bronchial asthma, peripheral eosinophilia, high levels of serum immunoglobulin E, pulmonary infiltration, mucoid impaction, and central bronchiectasis. Diagnosing ABPA is important to consider since there are treatment options that are readily available and response to therapy yields positive results. We describe a case of ABPA present in Trinidad, West Indies, which was not described previously in the literature.
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Affiliation(s)
- Dominic Dalip
- Internal Medicine, Southern Medical Clinic, San Fernando, TTO
| | - Brandon J Scott
- Emergency Medicine, Southern Medical Clinic, San Fernando, TTO
| | - Stanley Giddings
- Faculty of Clinical Medical Sciences, The University of the West Indies, Port of Spain, TTO
| | - Fidel S Rampersad
- Faculty of Clinical Medical Sciences, The University of the West Indies, Port of Spain, TTO.,Interventional Radiology, Southern Medical Clinic, San Fernando, TTO
| | - Shiva Jaggernauth
- Pulmonary Medicine, Southern Medical Clinic, San Fernando, TTO.,Pulmonary Medicine, Apley Medical Ltd, San Fernando, TTO
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Kumari J, Jat KR, Lodha R, Jana M, Xess I, Kabra SK. Prevalence and Risk Factors of Allergic Bronchopulmonary Aspergillosis and Aspergillus Sensitization in Children with Poorly Controlled Asthma. J Trop Pediatr 2020; 66:275-283. [PMID: 31580457 DOI: 10.1093/tropej/fmz066] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) may be a risk factor for poorly controlled asthma in children. The studies regarding prevalence and risk factors of ABPA in children with poorly controlled asthma are limited in number. OBJECTIVES To determine prevalence and risk factors of ABPA and aspergillus sensitization (AS) in children with poorly controlled asthma. METHODS In this prospective cross-sectional study from a tertiary care center in India, we enrolled asthmatic children 5-15 years of age with poorly controlled asthma. We did the following investigations: spirometry, skin prick test, serum total immunoglobulin E (IgE), aspergillus-specific IgE and immunoglobulin G, serum precipitin for Aspergillus, absolute eosinophil count, chest X-ray and high-resolution computed tomography of the chest. ABPA and AS were diagnosed as per the recently proposed criteria. RESULTS We enrolled 106 children [boys 72 (67.9%); mean age of 10.2 ± 2.6 years] with poorly controlled asthma. The prevalence of ABPA and AS were 11.3% (95% CI, 5.2-17.5%) and 61.3% (95% CI, 52.0-70.7%), respectively. The presence of brownish sputum was significantly more in ABPA compared with non-ABPA patients (33.3 vs. 4.2%, p = 0.002). The age, gender, allergic rhinitis and gastroesophageal reflux were not significantly different in ABPA compared with non-ABPA patients. CONCLUSION The prevalence of ABPA and AS was 11.3 and 61.3%, respectively in children with poorly controlled asthma. We could not find any risk factors for ABPA except that the presence of brownish sputum was more in children with ABPA. Spirometry parameters were not significantly different in ABPA compared with non-ABPA patients.
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Affiliation(s)
- Jyoti Kumari
- Department of Pediatrics, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - Kana Ram Jat
- Department of Pediatrics, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - Immaculata Xess
- Department of Microbiology, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - Sushil K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, 110029 New Delhi, India
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Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disease caused by Aspergillus induced hypersensitivity. It usually occurs in immunocompetent but susceptible patients with bronchial asthma and cystic fibrosis. If ABPA goes undiagnosed and untreated, it may progress to bronchiectasis and/or pulmonary fibrosis with significant morbidity and mortality. ABPA is a well-recognized entity in adults; however, there is lack of literature in children. The aim of the present review is to summarize pathophysiology, diagnostic criteria, clinical features, and treatment of ABPA with emphasis on the pediatric population. A literature search was undertaken through PubMed till April 30, 2018, with keywords “ABPA or allergic bronchopulmonary aspergillosis” with limitation to “title.” The relevant published articles related to ABPA in pediatric population were included for the review. The ABPA is very well studied in adults. Recently, it is increasingly being recognized in children. There is lack of separate diagnostic criteria of ABPA for children. Although there are no trials regarding treatment of ABPA in children, steroids and itraconazole are the mainstay of therapy based on studies in adults and observational studies in children. Omalizumab is upcoming therapy, especially in refractory ABPA cases. There is a need to develop the pediatric-specific cutoffs for diagnostic criteria in ABPA. Well-designed trials are required to determine appropriate treatment regimen in children.
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Affiliation(s)
- Kana Ram Jat
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj C Vaidya
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Joseph L Mathew
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Jondhale
- Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Meenu Singh
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Giovannini-Chami L, Blanc S, Hadchouel A, Baruchel A, Boukari R, Dubus JC, Fayon M, Le Bourgeois M, Nathan N, Albertini M, Clément A, de Blic J. Eosinophilic pneumonias in children: A review of the epidemiology, diagnosis, and treatment. Pediatr Pulmonol 2016; 51:203-16. [PMID: 26716396 DOI: 10.1002/ppul.23368] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/24/2015] [Accepted: 12/02/2015] [Indexed: 12/19/2022]
Abstract
Pediatric eosinophilic pneumonias (EPs) are characterized by a significant infiltration of the alveolar spaces and lung interstitium by eosinophils, with conservation of the lung structure. In developed countries, EPs constitute exceptional entities in pediatric care. Clinical symptoms may be transient (Löffler syndrome), acute (<1 month and mostly <7 days), or chronic (>1 month). Diagnosis relies on demonstration of alveolar eosinophilia on bronchoalveolar lavage, whether or not associated with blood eosinophilia. EPs are a heterogeneous group of disorders divided into: (i) secondary forms (seen mainly in parasitic infections, allergic bronchopulmonary aspergillosis, and drug reactions); and (ii) primary forms (eosinophilic granulomatosis with polyangiitis, hypereosinophilic syndrome, idiopathic chronic eosinophilic pneumonia, and idiopathic acute eosinophilic pneumonia). Despite their rarity, the etiological approach to EP must be well-defined as some causes can be rapidly life-threatening without initiation of the proper treatment. This approach (i) eliminates secondary forms, with comprehensive history taking and minimal biological assessment, (ii) is oriented in primary forms by the acute or chronic setting, and the existence of extrapulmonary symptoms. Treatment of primary forms has traditionally relied on corticosteroids, usually with a dramatic response. Specific treatments or the adjunction of corticosteroid-sparing treatment or immunosuppressors are currently being evaluated in order to improve the prognosis and the side effects associated with corticosteroid treatment in a pediatric setting.
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Affiliation(s)
- Lisa Giovannini-Chami
- Department of Pediatric Pulmonology and Allergology, Hôpitaux pédiatriques de Nice CHU-Lenval, Nice, France.,Université de Nice Sophia Antipolis, Nice, France
| | - Sibylle Blanc
- Department of Pediatric Pulmonology and Allergology, Hôpitaux pédiatriques de Nice CHU-Lenval, Nice, France
| | - Alice Hadchouel
- Department of Pediatric Pulmonology, AP-HP, Hôpital Necker Enfants Malades, Paris, France.,Université Paris Descartes-Paris 5, Paris, France
| | - André Baruchel
- Department of Pediatric Hematology, AP-HP, Hôpital Robert Debré, Paris, France.,Université Paris Diderot VII, Paris, France
| | - Rachida Boukari
- Department of Pediatric Pulmonology, Centre Hospitalier Universitaire Mustapha, Alger, Algérie
| | - Jean-Christophe Dubus
- Department of Pediatric Pulmonology, Centre Hospitalier Universitaire de Marseille, Marseille, France
| | - Michael Fayon
- Department of Pediatric Pulmonology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Département de Pédiatrie, Centre d'Investigation Clinique, Bordeaux, France
| | - Muriel Le Bourgeois
- Department of Pediatric Pulmonology, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Nadia Nathan
- Department of Pediatric Pulmonology, AP-HP, Hôpital Trousseau, Paris, France.,Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Marc Albertini
- Department of Pediatric Pulmonology and Allergology, Hôpitaux pédiatriques de Nice CHU-Lenval, Nice, France.,Université de Nice Sophia Antipolis, Nice, France
| | - Annick Clément
- Department of Pediatric Pulmonology, AP-HP, Hôpital Trousseau, Paris, France.,Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jacques de Blic
- Department of Pediatric Pulmonology, AP-HP, Hôpital Necker Enfants Malades, Paris, France.,Université Paris Descartes-Paris 5, Paris, France
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Current world literature. Curr Opin Allergy Clin Immunol 2012; 12:211-7. [PMID: 22382450 DOI: 10.1097/aci.0b013e3283520fda] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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