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Okada N, Yamamoto Y, Oguma T, Tanaka J, Tomomatsu K, Shiraishi Y, Matsuse H, Shimoda T, Kimura H, Watai K, Harada T, Fujita Y, Obase Y, Suzukawa M, Suzuki J, Takayanagi N, Ishiguro T, Masaki K, Fukunaga K, Asano K. Allergic bronchopulmonary aspergillosis with atopic, nonatopic, and sans asthma-Factor analysis. Allergy 2023; 78:2933-2943. [PMID: 37458287 DOI: 10.1111/all.15820] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/11/2023] [Accepted: 06/01/2023] [Indexed: 11/11/2023]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) develops in the presence or absence of asthma, either atopic or nonatopic. We have tried to explore the essential components in the pathogenesis of the disease, which are either consistent and variable according to the presence and type of asthma. METHODS Non-cystic fibrosis ABPA cases satisfying Asano's criteria were extracted from a prospective registry of ABPA and related diseases in Japan between 2013 and 2023. According to the type of preceding asthma, ABPA was classified into three groups: ABPA sans asthma (no preceding asthma), ABPA with atopic asthma, and ABPA with nonatopic asthma. Exploratory and confirmatory factor analyses were performed to identify the components that determined the clinical characteristics of ABPA. RESULTS Among 106 cases of ABPA, 25 patients (24%) had ABPA sans asthma, whereas 57 (54%) and 24 (23%) had ABPA with atopic and nonatopic asthma, respectively. Factor analysis identified three components: allergic, eosinophilic, and fungal. Patients with atopic asthma showed the highest scores for the allergic component (p < .001), defined by total and allergen-specific IgE titers and lung opacities, and the lowest scores for the fungal component defined by the presence of specific precipitin/IgG or positive culture for A. fumigatus. Eosinophilic components, including peripheral blood eosinophil counts and presence of mucus plugs/high attenuation mucus in the bronchi, were consistent among the three groups. CONCLUSION The eosinophilic component of ABPA is considered as the cardinal feature of ABPA regardless of the presence of preceding asthma or atopic predisposition.
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Affiliation(s)
- Naoki Okada
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Yoshiro Yamamoto
- Department of Mathematics, School of Science, Tokai University, Kanagawa, Japan
| | - Tsuyoshi Oguma
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Jun Tanaka
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Katsuyoshi Tomomatsu
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Yoshiki Shiraishi
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroto Matsuse
- Division of Respiratory Medicine, Department of Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Terufumi Shimoda
- Department of Allergy, Clinical Research Center, National Hospital Organization Fukuoka Hospital, Fukuoka, Japan
| | - Hirokazu Kimura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Kentaro Watai
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
- Center for Immunology and Allergy, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Toshiyuki Harada
- Center for Respiratory Diseases, Japan Community Healthcare Organization Hokkaido Hospital, Sapporo, Japan
| | - Yuka Fujita
- Department of Respiratory Medicine, National Hospital Organization Asahikawa Medical Center, Asahikawa, Japan
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Maho Suzukawa
- Clinical Research Center, National Hospital Organization Tokyo National Hospital, Kiyose, Japan
| | - Junko Suzuki
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Kiyose, Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Kumagaya, Japan
| | - Takashi Ishiguro
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Kumagaya, Japan
| | - Katsunori Masaki
- 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
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
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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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Agarwal R, Muthu V, Sehgal IS. Relationship between Aspergillus and asthma. Allergol Int 2023; 72:507-520. [PMID: 37633774 DOI: 10.1016/j.alit.2023.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/28/2023] Open
Abstract
Fungal sensitization is highly prevalent in severe asthma. The relationship between fungus and asthma, especially Aspergillus fumigatus, has been the subject of extensive research. The ubiquitous presence of A. fumigatus, its thermotolerant nature, the respirable size of its conidia, and its ability to produce potent allergens are pivotal in worsening asthma control. Due to the diverse clinical manifestations of fungal asthma and the lack of specific biomarkers, its diagnosis remains intricate. Diagnosing fungal asthma requires carefully assessing the patient's clinical history, immunological tests, and imaging. Depending on the severity, patients with fungal asthma require personalized treatment plans, including inhaled corticosteroids and bronchodilators, and antifungal therapy. This review provides a comprehensive overview of the association between Aspergillus and asthma by reviewing the relevant literature and highlighting key findings. We discuss the diagnosis of various entities included in fungal asthma. We also debate whether newer definitions, including allergic fungal airway disease, offer any additional advantages over the existing ones. Finally, we provide the current treatment options for the individual entities, including A. fumigatus-associated asthma, severe asthma with fungal sensitization, and allergic bronchopulmonary mycoses.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Xu X, Lu H, Li J, Duan J, Wang Z, Yang J, Gu S, Luo R, Liang S, Tang W, Zhang F, Hang J, Ge J, Lin X, Qu J, Jia X, Xu J. Heterozygous CARD9 mutation favors the development of allergic bronchopulmonary aspergillosis. Chin Med J (Engl) 2023; 136:1949-1958. [PMID: 37461235 PMCID: PMC10431571 DOI: 10.1097/cm9.0000000000002786] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Previous research demonstrated that a homozygous mutation of g.136372044G>A (S12N) in caspase recruitment domain family member 9 ( CARD9 ) is critical for producing Aspergillus fumigatus -induced ( Af -induced) T helper 2 (T H 2)-mediated responses in allergic bronchopulmonary aspergillosis (ABPA). However, it remains unclear whether the CARD9S12N mutation, especially the heterozygous occurrence, predisposes the host to ABPA. METHODS A total of 61 ABPA patients and 264 controls (including 156 healthy controls and 108 asthma patients) were recruited for sequencing the CARD9 locus to clarify whether patients with this heterozygous single-nucleotide polymorphisms are predisposed to the development of ABPA. A series of in vivo and in vitro experiments, such as quantitative real-time polymerase chain reaction, flow cytometry, and RNA isolation and quantification, were used to illuminate the involved mechanism of the disease. RESULTS The presence of the p.S12N mutation was associated with a significant risk of ABPA in ABPA patients when compared with healthy controls and asthma patients, regardless of Aspergillus sensitivity. Relative to healthy controls without relevant allergies, the mutation of p.S12N was associated with a significant risk of ABPA (OR: 2.69 and 4.17 for GA and AA genotypes, P = 0.003 and 0.029, respectively). Compared with patients with asthma, ABPA patients had a significantly higher heterozygous mutation (GA genotype), indicating that p.S12N might be a significant ABPA-susceptibility locus ( aspergillus sensitized asthma: OR: 3.02, P = 0.009; aspergillus unsensitized asthma: OR: 2.94, P = 0.005). The mutant allele was preferentially expressed in ABPA patients with heterozygous CARD9S12N , which contributes to its functional alterations to facilitate Af -induced T H 2-mediated ABPA development. In terms of mechanism, Card9 wild-type ( Card9WT ) expression levels decreased significantly due to Af -induced decay of its messenger RNA compared to the heterozygous Card9S12N . In addition, ABPA patients with heterozygous CARD9S12N had increased Af -induced interleukin-5 production. CONCLUSION Our study provides the genetic evidence showing that the heterozygous mutation of CARD9S12N , followed by allele expression imbalance of CARD9S12N , facilitates the development of ABPA.
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Affiliation(s)
- Xia Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai 200433, China
- Department of Immunology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Haiwen Lu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai 200433, China
| | - Jianxiong Li
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai 200433, China
| | - Jielin Duan
- Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Zhongwei Wang
- Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Jiawei Yang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai 200433, China
| | - Shuyi Gu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai 200433, China
| | - Rongguang Luo
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai 200433, China
| | - Shuo Liang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai 200433, China
| | - Wei Tang
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Fengying Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai Putuo District People's Hospital, Shanghai 200060, China
| | - Jingqing Hang
- Department of Respiratory and Critical Care Medicine, Shanghai Putuo District People's Hospital, Shanghai 200060, China
| | - Juan Ge
- Department of Respiratory and Critical Care Medicine, Nantong Hospital, Shanghai University, Nantong, Jiangsu 226007, China
| | - Xin Lin
- Institute for Immunology, Tsinghua University School of Medicine, Tsinghua-Peking Center for Life Sciences, Beijing 100083, China
| | - Jieming Qu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Xinming Jia
- Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Jinfu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Institute of Respiratory Medicine, School of Medicine, Tongji University, Shanghai 200433, China
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5
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Cottin V. Eosinophilic Lung Diseases. Immunol Allergy Clin North Am 2023; 43:289-322. [PMID: 37055090 DOI: 10.1016/j.iac.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
The eosinophilic lung diseases may manifest as chronic eosinophilic pneumonia, acute eosinophilic pneumonia, or as the Löffler syndrome (generally of parasitic etiology). The diagnosis of eosinophilic pneumonia is made when both characteristic clinical-imaging features and alveolar eosinophilia are present. Peripheral blood eosinophils are generally markedly elevated; however, eosinophilia may be absent at presentation. Lung biopsy is not indicated except in atypical cases after multidisciplinary discussion. The inquiry to possible causes (medications, toxic drugs, exposures, and infections especially parasitic) must be meticulous. Idiopathic acute eosinophilic pneumonia may be misdiagnosed as infectious pneumonia. Extrathoracic manifestations raise the suspicion of a systemic disease especially eosinophilic granulomatosis with polyangiitis. Airflow obstruction is frequent in allergic bronchopulmonary aspergillosis, idiopathic chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis, and hypereosinophilic obliterative bronchiolitis. Corticosteroids are the cornerstone of therapy, but relapses are common. Therapies targeting interleukin 5/interleukin-5 are increasingly used in eosinophilic lung diseases.
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Affiliation(s)
- Vincent Cottin
- Service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Centre de référence coordonnateur des maladies pulmonaires rares (OrphaLung), 28 Avenue Doyen Lepine, Lyon Cedex 69677, France; Université Lyon 1, INRAE, UMR754, Lyon, France.
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6
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Delcros Q, Groh M, Nasser M, Kahn JE, Cottin V. Steroid alternatives for managing eosinophilic lung diseases. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.2003777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Quentin Delcros
- National Reference Center for Hypereosinophilic Syndrome (Cereo)
- Department of Internal Medicine Hôpital Foch, Suresnes, France
| | - Matthieu Groh
- National Reference Center for Hypereosinophilic Syndrome (Cereo)
- Department of Internal Medicine Hôpital Foch, Suresnes, France
| | - Mouhamad Nasser
- Department of Respiratory Medicine, National Coordinating Reference Centre for Rare Pulmonary Diseases (Orphalung), Louis Pradel Hospital, Hospices Civils De Lyon, and Claude Bernard University Lyon 1, IVPC, Member of OrphaLung, RespiFIL and ERN-lung, France
| | - Jean-Emmanuel Kahn
- National Reference Center for Hypereosinophilic Syndrome (Cereo)
- Department of Internal Medicine, Hôpital Ambroise Paré, Université Paris Saclay, Assistance Publique Hôpitaux De Paris, Boulogne-Billancourt, France
| | - Vincent Cottin
- Department of Respiratory Medicine, National Coordinating Reference Centre for Rare Pulmonary Diseases (Orphalung), Louis Pradel Hospital, Hospices Civils De Lyon, and Claude Bernard University Lyon 1, IVPC, Member of OrphaLung, RespiFIL and ERN-lung, France
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7
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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.
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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
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8
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AllerScreener – A Server for Allergenicity and Cross-Reactivity Prediction. CYBERNETICS AND INFORMATION TECHNOLOGIES 2020. [DOI: 10.2478/cait-2020-0071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Allergenicity of proteins is a subtle property encoded in their structures. The prediction of allergenicity of novel proteins saves time and resources for subsequent experimental work. In the host antigen-presenting cells, the allergens are processed as antigens by the means of Human Leukocyte Antigens (HLA) class II proteins. Sometimes, people allergic to a given protein show allergic reaction to a different protein, even when the two proteins have different routes of exposure. This phenomenon is termed cross-reactivity. Here, we describe a server for allergenicity and cross-reactivity prediction based on the abilities of allergenic proteins to generate binders to HLA class II proteins. The generated peptides are compared to HLA binders originating from known allergens. As a result, the server returns a list of common binders, origin proteins, and species. Different species generate common HLA binders and this determines their cross-reactivity. The server is named AllerScreener and is freely accessible at:
http://www.ddg-pharmfac.net/AllerScreener
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9
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Barry J, Gadre A, Akuthota P. Hypersensitivity pneumonitis, allergic bronchopulmonary aspergillosis and other eosinophilic lung diseases. Curr Opin Immunol 2020; 66:129-135. [PMID: 33166785 DOI: 10.1016/j.coi.2020.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022]
Abstract
Hypersensitivity pneumonitis (HP) is traditionally classified into acute, subacute and chronic forms. A high index of suspicion and a detailed investigation into the patient's environment is the key to diagnosis and treatment of HP. Eosinophilic lung diseases can be broadly categorized as idiopathic (acute eosinophilic pneumonia, chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndromes), those with known cause (allergic bronchopulmonary aspergillosis, drugs, parasitic and non-parasitic infections), and those associated with other known lung diseases (asthma, interstitial lung diseases and lung cancers). A detailed review of drug intake, toxin exposures, and travel history is essential in the differential diagnosis of eosinophilic lung diseases.
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Affiliation(s)
- Jeffrey Barry
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States
| | - Abhishek Gadre
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States
| | - Praveen Akuthota
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States.
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10
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Tolebeyan A, Mohammadi O, Vaezi Z, Amini A. Mepolizumab as Possible Treatment for Allergic Bronchopulmonary Aspergillosis: A Review of Eight Cases. Cureus 2020; 12:e9684. [PMID: 32923277 PMCID: PMC7486017 DOI: 10.7759/cureus.9684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is an eosinophilic pulmonary disorder caused by a hypersensitivity reaction to Aspergillus fumigatus that manifests with uncontrolled asthma, peripheral blood eosinophilia, and radiological findings, such as mucus plugging. Early diagnosis and proper treatment of ABPA are essential to prevent irreversible lung damage such as pulmonary fibrosis and bronchiectasis and improve the quality of life of patients. Beside inhaled medication for asthma, anti-inflammatory agents (i.e., systemic glucocorticoids) and antifungal agents are the mainstay treatment of ABPA. The goal of therapy using glucocorticoids and antifungal agents is to suppress the immune hyperreactivity to A. fumigatus and attenuate the fungal burden. Since the systemic glucocorticoid therapy may lead to serious adverse effects including osteoporosis, avascular necrosis, myopathy, cushingoid appearance, hypertension, insomnia, and increased risk of infection, a glucocorticoid-sparing agent could be considered. Mepolizumab is a humanized monoclonal antibody that binds to interleukin-5, which is the key mediator for eosinophil differentiation, activation, migration, and survival. We review eight cases of ABPA treated successfully with mepolizumab. Treatment with mepolizumab was not restricted to the total immunoglobulin E level, the limiting factor for omalizumab in ABPA. In addition, mepolizumab therapy improved forced expiratory volume in one second, radiological findings, and patient quality of life.
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Affiliation(s)
| | - Oranus Mohammadi
- Internal Medicine, Aventura Hospital and Medical Center, Aventura, USA
| | - Zahra Vaezi
- Internal Medicine, Zahedan University of Medical Sciences, Zahedan, IRN
| | - Afshin Amini
- Internal Medicine, St. Luke's Hospital, Chesterfield, USA
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11
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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.
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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
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12
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Muthu V, Agarwal R. Allergic Bronchopulmonary Aspergillosis. CLINICAL PRACTICE OF MEDICAL MYCOLOGY IN ASIA 2020:137-164. [DOI: 10.1007/978-981-13-9459-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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13
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A Case of Allergic Bronchopulmonary Aspergillosis (ABPA) in a Patient with a History of Cocaine Use and Tuberculosis. Case Rep Med 2019; 2019:3265635. [PMID: 31871461 PMCID: PMC6907060 DOI: 10.1155/2019/3265635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 09/27/2019] [Accepted: 11/11/2019] [Indexed: 01/24/2023] Open
Abstract
Aspergillosis refers to a spectrum of disorders that can occur due to colonization with the Aspergillus fungus. Allergic bronchopulmonary aspergillosis (ABPA) is an airway hypersensitivity reaction to the fungus that is almost exclusively seen in patients with cystic fibrosis or asthma. Here, we present a case of ABPA in a patient with a history of chronic cocaine use and tuberculosis and no history of asthma or cystic fibrosis. The patient had presented with progressively worsening dyspnea for three months as well as a 20-pound weight loss. Diagnosis was made with an elevated IgE against Aspergillus and chest CT findings, which included bronchiectasis and tree-in-bud nodular opacities. The patient was treated with IV methylprednisolone followed by a 4-day course of oral prednisone, with significant improvement. It is our hope to make healthcare providers aware of the potential presence of ABPA in chronic cocaine users and patients with tuberculosis, both of which are not traditionally associated with this condition.
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14
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CARD9 S12N facilitates the production of IL-5 by alveolar macrophages for the induction of type 2 immune responses. Nat Immunol 2018; 19:547-560. [PMID: 29777223 DOI: 10.1038/s41590-018-0112-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/10/2018] [Indexed: 01/01/2023]
Abstract
The adaptor CARD9 functions downstream of C-type lectin receptors (CLRs) for the sensing of microbial infection, which leads to responses by the TH1 and TH17 subsets of helper T cells. The single-nucleotide polymorphism rs4077515 at CARD9 in the human genome, which results in the substitution S12N (CARD9S12N), is associated with several autoimmune diseases. However, the function of CARD9S12N has remained unknown. Here we generated CARD9S12N knock-in mice and found that CARD9S12N facilitated the induction of type 2 immune responses after engagement of CLRs. Mechanistically, CARD9S12N mediated CLR-induced activation of the non-canonical transcription factor NF-κB subunit RelB, which initiated production of the cytokine IL-5 in alveolar macrophages for the recruitment of eosinophils to drive TH2 cell-mediated allergic responses. We identified the homozygous CARD9 mutation encoding S12N in patients with allergic bronchopulmonary aspergillosis and revealed activation of RelB and production of IL-5 in peripheral blood mononuclear cells from these patients. Our study provides genetic and functional evidence demonstrating that CARD9S12N can turn alveolar macrophages into IL-5-producing cells and facilitates TH2 cell-mediated pathologic responses.
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15
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Benito-León J, Laurence M. The Role of Fungi in the Etiology of Multiple Sclerosis. Front Neurol 2017; 8:535. [PMID: 29085329 PMCID: PMC5650687 DOI: 10.3389/fneur.2017.00535] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 09/25/2017] [Indexed: 01/07/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system. Infectious triggers of MS are being actively investigated. Substantial evidence supports the involvement of the Epstein-Barr virus (EBV), though other viruses, bacteria, protists, and fungi are also being considered. Many links between fungi and diseases involving chronic inflammation have been found recently. Evidence linking MS and fungi is reviewed here. The HLA-DRB1*15 allele group is the most important genetic risk factor of MS, and is a risk factor in several other conditions linked to fungal infections. Many biomarkers of MS are consistent with fungal infections, such as IL-17, chitotriosidase, and antibodies against fungi. Dimethyl fumarate (DMF), first used as an industrial fungicide, was recently repurposed to reduce MS symptoms. Its mechanisms of action in MS have not been firmly established. The low risk of MS during childhood and its moderate association with herpes simplex virus type 2 suggest genital exposure to microbes (including fungi) should be investigated as a possible trigger. Molecular and epidemiological evidence support a role for infections such as EBV in MS. Though fungal infections have not been widely studied in MS, many lines of evidence are consistent with a fungal etiology. Future microbiome and serological studies should consider fungi as a possible risk factor for MS, and future clinical studies should consider the effect of fungicides other than DMF on MS symptoms.
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Affiliation(s)
- Julián Benito-León
- Department of Neurology, University Hospital “12 de Octubre”, Madrid, Spain
- Department of Medicine, Faculty of Medicine, Complutense University, Madrid, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
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16
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Wurster S, Weis P, Page L, Helm J, Lazariotou M, Einsele H, Ullmann AJ. Intra- and inter-individual variability of Aspergillus fumigatus reactive T-cell frequencies in healthy volunteers in dependency of mould exposure in residential and working environment. Mycoses 2017; 60:668-675. [PMID: 28786508 DOI: 10.1111/myc.12643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 05/08/2017] [Accepted: 05/12/2017] [Indexed: 01/08/2023]
Abstract
Invasive aspergillosis remains a deadly disease in immunocompromised patients, whereas the combination of an exaggerated immune response and continuous exposure lead to various hyperinflammatory diseases. This pilot study aimed to gain an overview of the intra- and inter-individual variability in Aspergillus fumigatus reactive T-helper cells in healthy adults and the correlation with environmental mould exposure. In this flow cytometric study, the frequencies of CD154+ A. fumigatus reactive T cells were evaluated in 70 healthy volunteers. All subjects completed a standardised questionnaire addressing their mould exposure. Subjects with intensive mould exposure in their professional or residential surrounding demonstrated considerably higher mean frequencies of A. fumigatus reactive T-helper and T-memory cells. Comparative evaluation of multiple measurements over time demonstrated relatively conserved reactive T-cell frequencies in the absence of major changes to the exposure profile, whereas those frequently exposed in professional environment or with changes to their risk score demonstrated a marked dependency of antigen reactive T-cell frequencies on recent mould exposure. This pilot study was the first to provide data on the intra-individual variability in A. fumigatus reactive T-cell frequencies and its linkage to mould encounter. Fungus reactive T cells are to be considered a valued tool for the assessment of environmental mould exposure.
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Affiliation(s)
- Sebastian Wurster
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Philipp Weis
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Lukas Page
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Johanna Helm
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Maria Lazariotou
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Andrew J Ullmann
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
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17
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Abstract
Allergic asthma refers to a chronic reversible bronchoconstriction influenced by an allergic trigger, leading to symptoms of cough, wheezing, shortness of breath, and chest tightness. Allergic bronchopulmonary aspergillosis is a complex hypersensitivity reaction, often in patients with asthma or cystic fibrosis, occurring when bronchi become colonized by Aspergillus species. The clinical picture is dominated by asthma complicated by recurrent episodes of bronchial obstruction, fever, malaise, mucus production, and peripheral blood eosinophilia. Hypersensitivity pneumonitis is a syndrome associated with lung inflammation from the inhalation of airborne antigens, such as molds and dust.
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Affiliation(s)
- Jason Raymond Woloski
- Department of Family Medicine, Penn State Hershey Medical Center, 500 University Drive, H154, PO Box 850, Hershey, PA 17033-0850, USA.
| | - Skye Heston
- Department of Family Medicine, Penn State Hershey Medical Center, 500 University Drive, H154, PO Box 850, Hershey, PA 17033-0850, USA
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18
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Weissler JC. Eosinophilic Lung Disease. Am J Med Sci 2017; 354:339-349. [PMID: 29078837 DOI: 10.1016/j.amjms.2017.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 02/22/2017] [Accepted: 03/13/2017] [Indexed: 12/28/2022]
Abstract
Eosinophils are involved in the pathogenesis of a number of lung diseases. Recent advances in eosinophil biology have now produced clinically applicable therapies that seek to counter eosinophilia in blood and lungs. This article reviews the basic biology of eosinophils and their role in mediating T-helper 2 cell responses. The current status of anticytokine therapy for eosinophilic lung disease is discussed. A clinical approach to eosinophilic lung disease based on symptoms and radiography is generated. The clinical significance of persistent eosinophilia in lung transplant patients and patients with asthma will receive special emphasis.
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Affiliation(s)
- Jonathan C Weissler
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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19
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Janahi IA, Rehman A, Al-Naimi AR. Allergic bronchopulmonary aspergillosis in patients with cystic fibrosis. Ann Thorac Med 2017; 12:74-82. [PMID: 28469716 PMCID: PMC5399694 DOI: 10.4103/atm.atm_231_16] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder that often occurs in patients with asthma or cystic fibrosis (CF) and is characterized by a hypersensitivity response to the allergens of the fungus Aspergillus fumigatus. In patients with CF, growth of A. fumigatus hyphae within the bronchial lumen triggers an immunoglobulin E (IgE)-mediated hypersensitivity response that results in airway inflammation, bronchospasm, and bronchiectasis. In most published studies, the prevalence of ABPA is about 8.9% in patients with CF. Since the clinical features of this condition overlap significantly with that of CF, ABPA is challenging to diagnose and remains underdiagnosed in many patients. Diagnosis of ABPA in CF patients should be sought in those with evidence of clinical and radiologic deterioration that is not attributable to another etiology, a markedly elevated total serum IgE level (while off steroid therapy) and evidence of A. fumigatus sensitization. Management of ABPA involves the use of systemic steroids to reduce inflammation and modulate the immune response. In patients who do not respond to steroids or cannot tolerate them, antifungal agents should be used to reduce the burden of A. fumigatus allergens. Recent studies suggest that omalizumab may be an effective option to reduce the frequency of ABPA exacerbations in patients with CF. Further randomized controlled trials are needed to better establish the efficacy of omalizumab in managing patients with CF and ABPA.
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Affiliation(s)
- Ibrahim Ahmed Janahi
- Department of Clinical Pediatrics, Weill Cornell Medical College-Qtar, Doha, Qatar.,Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Rehman
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Amal Rashid Al-Naimi
- Department of Clinical Pediatrics, Weill Cornell Medical College-Qtar, Doha, Qatar.,Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
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20
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Affiliation(s)
- Alan P Knutsen
- a Division of Allergy & Immunology, Department of Pediatrics , Saint Louis University , St. Louis , MO , USA
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21
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Thronicke A, Heger N, Antweiler E, Krannich A, Roehmel J, Brandt C, Staab D, Tintelnot K, Schwarz C. Allergic bronchopulmonary aspergillosis is associated with pet ownership in cystic fibrosis. Pediatr Allergy Immunol 2016; 27:597-603. [PMID: 27145047 DOI: 10.1111/pai.12590] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Late diagnosis of allergic bronchopulmonary aspergillosis (ABPA) is associated with significant lung function decline and morbidity in cystic fibrosis (CF). The association of ABPA and domestic pet ownership in patients with CF has not been elucidated yet. Our objective was to determine the association of ABPA with pet ownership in patients with CF. METHODS Clinical and microbiological data from certified local patient registry were analyzed for 109 patients with CF aged 1-64 years: 55 pet owner and 54 non-pet owners. The primary outcome of the retrospective observational study was the occurrence of ABPA in pet owners and non-pet owners with CF. The free statistical software R was utilized to investigate logistic regression models for association factors. RESULTS Of the 109 patients included in the study, 61 (56%) were female. The mean age of the total group was 25.4 ± 13.2 years. Adjusted analysis revealed that ABPA (OR 5.0227, 95% CI: 1.182-21.340, p = 0.029) was associated with pet ownership in patients with CF. Furthermore, ABPA in pet owners with CF was associated with an increased number of exacerbations (OR 6.446, 95% CI: 1.057-39.328, p = 0.043). Other outcomes did not significantly differ. CONCLUSION Owning a pet was associated with ABPA in patients with CF. Future prospective multicenter longitudinal studies are needed to investigate chronological causality between pet ownership, ABPA development, and pulmonary exacerbations and to determine whether these estimates are generalizable for ABPA susceptible patients beyond CF (asthma, bronchiectasis).
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Affiliation(s)
- Anja Thronicke
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nikola Heger
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Elisabeth Antweiler
- Reference Laboratory for Cryptococcosis, Scedosporiosis and Imported Systemic Mycoses, FG16, Robert Koch Institute, Berlin, Germany
| | - Alexander Krannich
- Biostatistics Unit, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jobst Roehmel
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Brandt
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Doris Staab
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kathrin Tintelnot
- Reference Laboratory for Cryptococcosis, Scedosporiosis and Imported Systemic Mycoses, FG16, Robert Koch Institute, Berlin, Germany
| | - Carsten Schwarz
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
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22
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Kobayashi H, Taira T, Wakuda K, Takahashi T, Endo M. A favorable clinical effect of an expectorant in allergic bronchopulmonary mycosis caused by Schizophyllum commune. Respir Med Case Rep 2016; 19:54-7. [PMID: 27489762 PMCID: PMC4961680 DOI: 10.1016/j.rmcr.2016.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/08/2016] [Accepted: 07/11/2016] [Indexed: 01/15/2023] Open
Abstract
An 80-year-old Japanese woman with wet cough and dyspnea was diagnosed with pneumonia at a clinic. Antibiotics did not improve her symptoms; therefore, she was referred to our hospital one month after symptom onset. Chest radiograph findings revealed complete collapse of the left lung. Bronchoscopy showed white mucus plug in the left main bronchus, which could not be removed. She was initially treated with bromhexine. Subsequently, culture results of the mucus plug specimen obtained during bronchoscopy yielded Schizophyllum commune. After three weeks, improvement of the collapsed lung was observed on chest radiograph.
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Affiliation(s)
- Haruki Kobayashi
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tetsuhiko Taira
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kazushige Wakuda
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Masahiro Endo
- Division of Diagnostic Radiology, Shizuoka Cancer Center, Shizuoka, Japan
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23
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Abstract
Eosinophilic lung diseases especially comprise eosinophilic pneumonia or as the more transient Löffler syndrome, which is most often due to parasitic infections. The diagnosis of eosinophilic pneumonia is based on characteristic clinical-imaging features and the demonstration of alveolar eosinophilia, defined as at least 25% eosinophils at BAL. Peripheral blood eosinophilia is common but may be absent at presentation in idiopathic acute eosinophilic pneumonia, which may be misdiagnosed as severe infectious pneumonia. All possible causes of eosinophilia, including drug, toxin, fungus related etiologies, must be thoroughly investigated. Extrathoracic manifestations should raise the suspicion of eosinophilic granulomatosis with polyangiitis.
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24
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Rodrigues J, Caruthers C, Azmeh R, Dykewicz MS, Slavin RG, Knutsen AP. The spectrum of allergic fungal diseases of the upper and lower airways. Expert Rev Clin Immunol 2016; 12:531-50. [PMID: 26776889 DOI: 10.1586/1744666x.2016.1142874] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fungi cause a wide spectrum of fungal diseases of the upper and lower airways. There are three main phyla involved in allergic fungal disease: (1) Ascomycota (2) Basidiomycota (3) Zygomycota. Allergic fungal rhinosinusitis (AFRS) causes chronic rhinosinusitis symptoms and is caused predominantly by Aspergillus fumigatus in India and Bipolaris in the United States. The recommended treatment approach for AFRS is surgical intervention and systemic steroids. Allergic bronchopulmonary aspergillosis (APBA) is most commonly diagnosed in patients with asthma or cystic fibrosis. Long term systemic steroids are the mainstay treatment option for ABPA with the addition of an antifungal medication. Fungal sensitization or exposure increases a patient's risk of developing severe asthma and has been termed severe asthma associated with fungal sensitivity (SAFS). Investigating for triggers and causes of a patient's asthma should be sought to decrease worsening progression of the disease.
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Affiliation(s)
| | - Carrie Caruthers
- a Allergy & Immunology , Saint Louis University , St. Louis , MO , USA
| | - Roua Azmeh
- a Allergy & Immunology , Saint Louis University , St. Louis , MO , USA
| | - Mark S Dykewicz
- a Allergy & Immunology , Saint Louis University , St. Louis , MO , USA
| | - Raymond G Slavin
- a Allergy & Immunology , Saint Louis University , St. Louis , MO , USA
| | - Alan P Knutsen
- a Allergy & Immunology , Saint Louis University , St. Louis , MO , USA
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25
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Jolink H, de Boer R, Willems LNA, van Dissel JT, Falkenburg JHF, Heemskerk MHM. T helper 2 response in allergic bronchopulmonary aspergillosis is not driven by specific Aspergillus antigens. Allergy 2015; 70:1336-9. [PMID: 26179335 DOI: 10.1111/all.12688] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2015] [Indexed: 12/11/2022]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is characterized by an allergic immunological response to Aspergillus fumigatus. In this study, we investigated whether certain Aspergillus antigens are more allergenic than others, as was postulated previously. We stimulated peripheral blood mononuclear cells from patients with ABPA with the classically described A. fumigatus allergens Aspf1, Aspf2, Aspf3, and Aspf4, as well as two other Aspergillus antigens, Crf1 and Catalase1. Activated CD4+ T cells displayed a T helper 2 phenotype with the production of IL-4 in response to stimulation with several of these different antigens. Immune responses were not limited to the classically described A. fumigatus allergens. In healthy individuals, we demonstrated a similar recognition profile to the different antigens, but in contrast the activated CD4+ T cells exerted a T helper 1 phenotype and mainly produced IFN-γ after stimulation with A. fumigatus antigens. In conclusion, irrespective of the A. fumigatus antigen, the T-cell immune response in patients with ABPA is skewed to a T helper 2 cytokine secretion profile.
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Affiliation(s)
- H. Jolink
- Department of Hematology; Leiden University Medical Center; Leiden the Netherlands
- Department of Infectious Diseases; Leiden University Medical Center; Leiden the Netherlands
| | - R. de Boer
- Department of Hematology; Leiden University Medical Center; Leiden the Netherlands
| | - L. N. A. Willems
- Department of Pulmonary Medicine; Leiden University Medical Center; Leiden the Netherlands
| | - J. T. van Dissel
- Department of Infectious Diseases; Leiden University Medical Center; Leiden the Netherlands
| | - J. H. F. Falkenburg
- Department of Hematology; Leiden University Medical Center; Leiden the Netherlands
| | - M. H. M. Heemskerk
- Department of Hematology; Leiden University Medical Center; Leiden the Netherlands
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26
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Becker KL, Gresnigt MS, Smeekens SP, Jacobs CW, Magis-Escurra C, Jaeger M, Wang X, Lubbers R, Oosting M, Joosten LAB, Netea MG, Reijers MH, van de Veerdonk FL. Pattern recognition pathways leading to a Th2 cytokine bias in allergic bronchopulmonary aspergillosis patients. Clin Exp Allergy 2015; 45:423-37. [PMID: 24912986 DOI: 10.1111/cea.12354] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 04/23/2014] [Accepted: 06/02/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is characterised by an exaggerated Th2 response to Aspergillus fumigatus, but the immunological pathways responsible for this effect are unknown. OBJECTIVE The aim of this study was to decipher the pattern recognition receptors (PRRs) and cytokines involved in the Aspergillus-specific Th2 response and to study Aspergillus-induced responses in healthy controls and ABPA patients. METHODS Peripheral blood mononuclear cells (PBMCs) were stimulated with heat-killed Aspergillus conidia, various other pathogens, or PRR ligands. PRRs and cytokine pathways were blocked with PRR-blocking reagents, anti-TNF (Etanercept or Adalimumab), IL-1Ra (Anakinra) or IFNγ (IFN-gamma). ELISA and FACS were used to analyse cytokine responses. RESULTS Aspergillus was the only pathogen that stimulated the Th2 cytokines IL-5 and IL-13, while Gram-negative bacteria, Gram-positive bacteria, Candida albicans, chitin, β-glucan or Toll-like receptor (TLR) ligands did not. Depletion of CD4(+) cells abolished IL-13 production. Blocking complement receptor 3 (CR3) significantly reduced IL-5 and IL-13, while blocking TLR2, TLR4 or dectin-1 had no effect. ABPA patients displayed increased Aspergillus-induced IL-5 and IL-13 and decreased IFNγ production compared with healthy controls. All biological agents tested showed the capability to inhibit Th2 responses, but also decreased Aspergillus-induced IFNγ. CONCLUSIONS AND CLINICAL RELEVANCE Aspergillus conidia are unique in triggering Th2 responses in human PBMCs, through a CR3-dependent pathway. ABPA patients display a significantly increased Aspergillus-induced Th2/Th1 ratio that can be modulated by biologicals. These data provide a rationale to explore IFNγ therapy in ABPA as a corticosteroid-sparing treatment option, by dampening Th2 responses and supplementing the IFNγ deficiency at the same time.
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Affiliation(s)
- K L Becker
- Department of Internal Medicine, Radboud University Nijmegen, Medical Centre and Nijmegen Institute for Infection, Inflammation, and Immunity (N4i), Nijmegen, The Netherlands
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27
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Mirković B, Lavelle GM, Azim AA, Helma K, Gargoum FS, Molloy K, Gernez Y, Dunne K, Renwick J, Murphy P, Moss RB, Greene CM, Gunaratnam C, Chotirmall SH, McElvaney NG. The basophil surface marker CD203c identifies Aspergillus species sensitization in patients with cystic fibrosis. J Allergy Clin Immunol 2015; 137:436-443.e9. [PMID: 26388311 DOI: 10.1016/j.jaci.2015.07.045] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 07/04/2015] [Accepted: 07/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Colonization by Aspergillus fumigatus in patients with cystic fibrosis (CF) can cause A fumigatus sensitization and/or allergic bronchopulmonary aspergillosis (ABPA), which affects pulmonary function and clinical outcomes. Recent studies show that specific allergens upregulate the surface-expressed basophil marker CD203c in sensitized subjects, a response that can be readily measured by using flow cytometry. OBJECTIVE We sought to identify A fumigatus sensitization in patients with CF by using the basophil activation test (BAT). METHODS Patients with CF attending Beaumont Hospital were screened for study inclusion. BAT was used to identify A fumigatus sensitization. Serologic (total and A fumigatus-specific IgE), pulmonary function, and body mass index measurements were performed. RESULTS The BAT discriminates A fumigatus-sensitized from nonsensitized patients with CF. Persistent isolation of A fumigatus in sputum is a significant risk factor for A fumigatus sensitization. Levels of the A fumigatus-stimulated basophil activation marker CD203c inversely correlated with pulmonary function and body mass index in A fumigatus-sensitized but not nonsensitized patients with CF. Total and A fumigatus-specific IgE, but not IgG, levels are increased in A fumigatus-sensitized patients with CF and ABPA when compared with those in A fumigatus-sensitized and nonsensitized patients with CF without ABPA. Itraconazole treatment did not affect A fumigatus sensitization. CONCLUSION Combining the BAT with routine serologic testing allows classification of patients with CF into 3 groups: nonsensitized, A fumigatus-sensitized, and ABPA. Accurate and prompt identification of A fumigatus-associated clinical status might allow early and targeted therapeutic intervention, potentially improving clinical outcomes.
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Affiliation(s)
- Bojana Mirković
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Gillian M Lavelle
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Ahmed Abdul Azim
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Kristine Helma
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Fatma S Gargoum
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Kevin Molloy
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Yael Gernez
- Department of Genetics, Stanford University School of Medicine, Stanford, Calif
| | - Katie Dunne
- Clinical Microbiology Department, Trinity College Dublin, the Adelaide and Meath Hospital incorporating the National Children's Hospital, Tallaght, Dublin, Ireland
| | - Julie Renwick
- Clinical Microbiology Department, Trinity College Dublin, the Adelaide and Meath Hospital incorporating the National Children's Hospital, Tallaght, Dublin, Ireland
| | - Philip Murphy
- Clinical Microbiology Department, Trinity College Dublin, the Adelaide and Meath Hospital incorporating the National Children's Hospital, Tallaght, Dublin, Ireland
| | - Richard B Moss
- Center for Excellence in Pulmonary Biology, Department of Paediatrics, Stanford University School of Medicine, Stanford, Calif
| | - Catherine M Greene
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Cedric Gunaratnam
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
| | - Noel G McElvaney
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
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28
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Blauvelt DG, Castellanos A, Stern TA, Puig A. Necrotising pneumonia and bronchiectasis in a previously healthy 30-year-old man. BMJ Case Rep 2015; 2015:bcr-2014-207747. [PMID: 25608981 DOI: 10.1136/bcr-2014-207747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of a previously healthy 30-year-old man who presented with a necrotising pneumonia and bronchiectasis. His infectious workup revealed a Staphylococcus aureus pneumonia. Since bronchiectasis and necrotising pneumonia are unusual findings in an otherwise healthy person, further investigation was pursued. His workup revealed non-classic cystic fibrosis (CF) and allergic bronchopulmonary aspergillosis (ABPA). This case discusses the differential diagnosis of bronchiectasis, the diagnosis and treatment of ABPA, and the role of CF mutations in the pathogenesis of ABPA.
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Affiliation(s)
| | | | | | - Alberto Puig
- Massachusetts General Hospital, Boston, Massachusetts, USA
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Greenberger PA, Bush RK, Demain JG, Luong A, Slavin RG, Knutsen AP. Allergic bronchopulmonary aspergillosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2014; 2:703-8. [PMID: 25439360 PMCID: PMC4306287 DOI: 10.1016/j.jaip.2014.08.007] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 01/03/2023]
Abstract
There remains a lack of agreement on diagnostic criteria and approaches to treatment of patients with allergic bronchopulmonary aspergillosis (ABPA). The results of a survey of American Academy of Allergy, Asthma, & Immunology members regarding these 2 issues are presented and compared for concordance with published recommendations. The literature was reviewed for pertinent reports, and an electronic survey was conducted of American Academy of Allergy, Asthma, & Immunology members and fellows regarding diagnostic criteria, numbers of patients evaluated for ABPA, and treatment approaches. From 508 respondents to the survey sent to 5155 US physicians in the American Academy of Allergy, Asthma, & Immunology database of members and fellows, 245 health professionals (48%) had treated at least 1 patient with ABPA in the previous year. For the diagnosis of ABPA, there was a difference in the threshold concentration of total serum IgE because 44.9% used ≥417 kU/L, whereas 42.0% used ≥1000 kU/L. Analysis of these findings suggests that ABPA might be underdiagnosed. With regard to pharmacotherapy, oral steroids were recommended for 97.1% of patients and oral steroids plus inhaled corticosteroids plus antifungal agent were used with 41.2% of patients. The armamentarium for treatment of ABPA includes oral corticosteroids as the initial treatment with inhaled corticosteroids used for management of persistent asthma. Azoles remain adjunctive. Published experience with omalizumab has been limited.
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MESH Headings
- Administration, Inhalation
- Administration, Oral
- Adrenal Cortex Hormones/administration & dosage
- Adrenal Cortex Hormones/adverse effects
- Allergy and Immunology/standards
- Antifungal Agents/adverse effects
- Antifungal Agents/therapeutic use
- Aspergillosis, Allergic Bronchopulmonary/blood
- Aspergillosis, Allergic Bronchopulmonary/diagnosis
- Aspergillosis, Allergic Bronchopulmonary/epidemiology
- Aspergillosis, Allergic Bronchopulmonary/genetics
- Aspergillosis, Allergic Bronchopulmonary/immunology
- Aspergillosis, Allergic Bronchopulmonary/microbiology
- Aspergillosis, Allergic Bronchopulmonary/therapy
- Biomarkers/blood
- Genetic Predisposition to Disease
- Guideline Adherence
- Health Care Surveys
- Humans
- Immunoglobulin E/blood
- Practice Guidelines as Topic
- Practice Patterns, Physicians'
- Predictive Value of Tests
- Risk Factors
- Treatment Outcome
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Affiliation(s)
- Paul A Greenberger
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Robert K Bush
- Division of Allergy-Immunology, Department of Medicine, University of Wisconsin, Madison, Wis
| | - Jeffrey G Demain
- Allergy, Asthma and Immunology Center of Alaska, University of Washington, Anchorage, Alaska
| | - Amber Luong
- Otolaryngology-Head and Neck Surgery, University of Texas Medical School at Houston, Houston, Texas
| | - Raymond G Slavin
- Section of Allergy-Immunology, Division of Infectious Diseases, Department of Internal Medicine, St Louis University, St Louis, Mo
| | - Alan P Knutsen
- Division of Allergy-Immunology, Department of Pediatrics, St Louis University, St Louis, Mo
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Agarwal R, Devi D, Gupta D, Chakrabarti A. A questionnaire-based study on the role of environmental factors in allergic bronchopulmonary aspergillosis. Lung India 2014; 31:232-6. [PMID: 25125809 PMCID: PMC4129594 DOI: 10.4103/0970-2113.135762] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background and Aims: Allergic bronchopulmonary aspergillosis (ABPA) is an immunological disorder caused by hypersensitivity against Aspergillus fumigatus. The pathogenesis of ABPA remains unknown. Few studies have investigated the role of environmental factors in pathogenesis of ABPA. Herein, we investigate the role of environmental factors in ABPA. Materials and Methods: In this prospective case-control study, consecutive patients with asthma (Aspergillus sensitized and unsensitized) and ABPA were investigated using a standardized questionnaire to enquire into their demographic characteristics, clinical details, exposure to organic matter and living conditions (home environment, presence of moisture in the walls, and others). Asthma severity and control was assessed using the 2002 The Global Initiative for Asthma (GINA) recommendations and asthma control test, respectively. Results: During the study period, 202 subjects of asthma (103 and 99 Aspergillus unsensitized and sensitized asthma, respectively) and 101 ABPA with a mean (SD) age of 35.3 (14.7) years were included. The baseline characteristics were similar in the two groups except for a higher prevalence of severe persistent asthma in the ABPA group (79% vs. 44%, P = 0.0001). No significant differences in environmental factors were noted in the ABPA population compared to asthmatic patients except for a higher rural residence in ABPA (47% vs. 66%, P = 0.007). Conclusions: The study found no significant environmental differences in ABPA compared to asthmatic patients. It is likely that environmental factors are not the primary pathogenetic factors in causation of ABPA.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Durga Devi
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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31
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Callejas CA, Douglas RG. Fungal rhinosinusitis: what every allergist should know. Clin Exp Allergy 2014; 43:835-49. [PMID: 23889239 DOI: 10.1111/cea.12118] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 02/06/2013] [Accepted: 02/22/2013] [Indexed: 01/02/2023]
Abstract
The interaction between fungi and the sinonasal tract results in a diverse range of diseases with an equally broad spectrum of clinical severity. The classification of these interactions has become complex, and this review seeks to rationalize and simplify the approach to fungal diseases of the nose and paranasal sinuses. These conditions may be discussed under two major headings: non-invasive disease (localized fungal colonization, fungal ball and allergic fungal rhinosinusitis) and invasive disease (acute invasive rhinosinusitis, chronic invasive rhinosinusitis and granulomatous invasive rhinosinusitis). A diagnosis of fungal rhinosinusitis is established by combining findings on history, clinical examination, laboratory testing, imaging and histopathology. The immunocompetence of the patient is of great importance, as invasive fungal rhinosinusitis is uncommon in immunocompetent patients. With the exception of localized fungal colonization, treatment of all forms of fungal rhinosinusitis relies heavily on surgery. Systemic antifungal agents are a fundamental component in the treatment of invasive forms, but are not indicated for the treatment of the non-invasive forms. Antifungal drugs may have a role as adjuvant therapy in allergic fungal rhinosinusitis, but evidence is poor to support recommendations. Randomized controlled trials need to be performed to confirm the benefit of immunotherapy in the treatment of allergic fungal rhinosinusitis. In this article, we will summarize the current literature, addressing the controversies regarding the diagnosis and management of fungal rhinosinusitis, and focussing on those aspects which are important for clinical immunologists and allergists.
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Affiliation(s)
- C A Callejas
- Otorhinolaryngology Department, Pontificia Universidad Católica de Chile, Santiago, Chile
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32
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Wu Y, Liang Y, Wei K, Li W, Yao M, Zhang J. Rapid allergen inactivation using atmospheric pressure cold plasma. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2014; 48:2901-2909. [PMID: 24490983 DOI: 10.1021/es5003988] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Allergies have become a global problem, and effective control is greatly needed. Here, the inactivation effects of the atmospheric pressure cold plasma (APCP) on aerosolized allergens including Der p 1, Der f 1, Asp f 1, Alt a 1, and Can f 1 as well as those from indoor and outdoor environments were investigated. The effectiveness of the APCP treatment was further studied using blood sera from the allergen sensitized humans. In addition, the allergen samples were also analyzed using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). Results revealed that the APCP was highly effective in reducing the allergenicity of both lab-prepared and environmental allergen aerosols. The airborne reductions were shown to range from 30% for Der p 1 to 80% for Can f 1 allergen for 0.12 s exposure. Allergnicity tests showed that the APCP treated Asp f 1 allergens caused 50% less binding with IgEs in the blood sera compared to the control. The observed allergenicity loss was due to hydroxyl radicals produced by the plasma device. The results from SDS-PAGE showed that the plasma treatment resulted in decreased size of the Asp f 1 allergen. The developed technology holds great promise in combating the allergic diseases.
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Affiliation(s)
- Yan Wu
- State Key Joint Laboratory of Environmental Simulation and Pollution Control, College of Environmental Sciences and Engineering, Peking University , Beijing 100871, China
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Hafen GM, Hartl D, Regamey N, Casaulta C, Latzin P. Allergic bronchopulmonary aspergillosis: the hunt for a diagnostic serological marker in cystic fibrosis patients. Expert Rev Mol Diagn 2014; 9:157-64. [DOI: 10.1586/14737159.9.2.157] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Agarwal R, Chakrabarti A, Shah A, Gupta D, Meis JF, Guleria R, Moss R, Denning DW. Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria. Clin Exp Allergy 2013; 43:850-873. [DOI: 10.1111/cea.12141] [Citation(s) in RCA: 537] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- R. Agarwal
- Department of Pulmonary Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - A. Chakrabarti
- Division of Medical Mycology; Department of Medical Microbiology; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - A. Shah
- Department of Pulmonary Medicine; Vallabhbhai Patel Chest Institute; University of Delhi; New Delhi India
| | - D. Gupta
- Department of Pulmonary Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - J. F. Meis
- Department of Medical Microbiology and Infectious Diseases; Canisius-Wilhelmina Hospital; Nijmegen The Netherlands
- Department of Medical Microbiology; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - R. Guleria
- Department of Internal Medicine; All India Institute of Medical Sciences; New Delhi India
| | - R. Moss
- Department of Pediatrics; Stanford University; Palo Alto CA USA
| | - D. W. Denning
- Manchester Academic Health Science Centre; The National Aspergillosis Centre; University of Manchester; University Hospital of South Manchester; Manchester UK
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36
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The immune interplay between the host and the pathogen in Aspergillus fumigatus lung infection. BIOMED RESEARCH INTERNATIONAL 2013; 2013:693023. [PMID: 23984400 PMCID: PMC3745895 DOI: 10.1155/2013/693023] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 06/14/2013] [Indexed: 12/22/2022]
Abstract
The interplay between Aspergillus fumigatus and the host immune response in lung infection has been subject of studies over the last years due to its importance in immunocompromised patients. The multifactorial virulence factors of A. fumigatus are related to the fungus biological characteristics, for example, structure, ability to grow and adapt to high temperatures and stress conditions, besides capability of evading the immune system and causing damage to the host. In this context, the fungus recognition by the host innate immunity occurs when the pathogen disrupts the natural and chemical barriers followed by the activation of acquired immunity. It seems clear that a Th1 response has a protective role, whereas Th2 reactions are often associated with higher fungal burden, and Th17 response is still controversial. Furthermore, a fine regulation of the effector immunity is required to avoid excessive tissue damage associated with fungal clearance, and this role could be attributed to regulatory T cells. Finally, in this work we reviewed the aspects involved in the complex interplay between the host immune response and the pathogen virulence factors, highlighting the immunological issues and the importance of its better understanding to the development of novel therapeutic approaches for invasive lung aspergillosis.
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37
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Matsuse H, Tsuchida T, Fukahori S, Kawano T, Nishino T, Fukushima C, Kohno S. Dissociation between sensitizing and colonizing fungi in patients with allergic bronchopulmonary aspergillosis. Ann Allergy Asthma Immunol 2013; 111:190-3. [PMID: 23987194 DOI: 10.1016/j.anai.2013.06.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 06/13/2013] [Accepted: 06/17/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Because allergic bronchopulmonary aspergillosis (ABPA) does not require the presence of Aspergillus fumigatus for diagnosis, serological and radiological findings without cultures usually confirm this condition. OBJECTIVE To determine which fungi colonize the airways of patients with definitive ABPA. METHODS We enrolled 11 patients (ages 57.5 ± 17.1 years; male: female, 4:7) with ABPA diagnosed by serological and radiological criteria. Fungi colonizing the airway were identified from mucous plugs that were naturally expectorated or obtained by fiberoptic bronchoscopy. RESULTS Aspergillus spp. (n = 8) was the most frequently isolated, followed by Schizophyllum commune (n = 4), Candida albicans (n = 2), Rhizopus oryzae (n = 1), and Penicillium spp. (n = 1). Among the Aspergillus spp., A. niger, A. terreus, and A. sydowii were more frequently isolated (total, n = 6) than A. fumigatus (n = 2). Many patients were sensitized with several fungi in addition to Aspergillus, which were dissociated with airway-colonizing fungi. CONCLUSION Multiple fungal species can colonize the airway, and dissociation between colonizing and sensitizing species frequently occurs in definitive ABPA. Considering the increased prevalence of azole-resistant Aspergillus spp., administering antifungal drugs that target A. fumigatus without identifying which fungal species colonize the airway might be problematic.
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Affiliation(s)
- Hiroto Matsuse
- Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan.
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38
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Abstract
This review starts with discussions of several infectious causes of eosinophilic pneumonia, which are almost exclusively parasitic in nature. Pulmonary infections due specifically to Ascaris, hookworms, Strongyloides, Paragonimus, filariasis, and Toxocara are considered in detail. The discussion then moves to noninfectious causes of eosinophilic pulmonary infiltration, including allergic sensitization to Aspergillus, acute and chronic eosinophilic pneumonias, Churg-Strauss syndrome, hypereosinophilic syndromes, and pulmonary eosinophilia due to exposure to specific medications or toxins.
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39
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Immunological aspects of Candida and Aspergillus systemic fungal infections. Interdiscip Perspect Infect Dis 2013; 2013:102934. [PMID: 23401680 PMCID: PMC3564277 DOI: 10.1155/2013/102934] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 01/02/2013] [Indexed: 01/17/2023] Open
Abstract
Patients with allogeneic stem cell transplantation (SCT) have a high risk of invasive fungal infections (IFIs) even after neutrophil regeneration. Immunological aspects might play a very important role in the IFI development in these patients. Some data are available supporting the identification of high-risk patients with IFI for example patients receiving stem cells from TLR4 haplotype S4 positive donors. Key defense mechanisms against IFI include the activation of neutrophils, the phagocytosis of germinating conidia by dendritic cells, and the fight of the cells of the innate immunity such as monocytes and natural killer cells against germlings and hyphae. Furthermore, immunosuppressive drugs interact with immune effector cells influencing the specific fungal immune defense and antimycotic drugs might interact with immune response. Based on the current knowledge on immunological mechanism in Aspergillus fumigatus, the first approaches of an immunotherapy using human T cells are in development. This might be an option for the future of aspergillosis patients having a poor prognosis with conventional treatment.
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41
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Kurup VP, Banerjee B, Kelly KJ, Fink JN. Molecular biology and immunology of fungal allergens. Indian J Clin Biochem 2012; 15:31-42. [PMID: 23105266 DOI: 10.1007/bf02867542] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Fungi are non-chlorophyllus microorganisms, which constitutes the main source of outdoor and indoor allergens. The antigens present in the spores and fragments of hyphae induce allergic responses in sensitized patients. The frequently recognized fungi associated with asthma include Alternaria, Cladosporium, Aspergillus, and Penicillium. With the advent of molecular biology techniques a number of fungal genes encoding relevant allergens have been cloned and the expressed allergens purified and characterized. In this review, we have presented the recent developments, where recombinant allergens have been used in the precise diagnosis of fungal allergy. We have also discussed the role played by these allergens and the T- and B-cell epitopes in the immune mechanism in fungal allergy.
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Affiliation(s)
- V P Kurup
- Department of Pediatrics, Medical College of Wisconsin, and Research Service, Allergy-Immunology Division, VA Medical Center, 5000 West National Avenue Milwaukee, WI, 151-1, 53295 Milwaukee, Wisconsin USA
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Mahdavinia M, Grammer LC. Management of allergic bronchopulmonary aspergillosis: a review and update. Ther Adv Respir Dis 2012; 6:173-87. [PMID: 22547692 DOI: 10.1177/1753465812443094] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Since the first description of allergic bronchopulmonary aspergillosis (ABPA) in the 1950s there have been numerous studies that have shed light on the characteristics and immunopathogenesis of this disease. The increased knowledge and awareness have resulted in earlier diagnosis and treatment of patients with this condition. This article aims to provide a summary and updates on ABPA by reviewing the results of recent studies on this disease with a focus on articles published within the last 5 years. A systematic search of PubMed/Medline with keywords of ABPA or allergic bronchopulmonary aspergillosis was performed. All selected articles were reviewed with a focus on findings of articles published from December 2006 to December 2011. The relevant findings are summarized in this paper.
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Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is caused by an exaggerated T(H)2 response to the ubiquitous mold Aspergillus fumigatus. ABPA develops in a small fraction of patients with cystic fibrosis and asthma, suggesting that intrinsic host defects play a major role in disease susceptibility. This article reviews current understanding of the immunopathology, clinical and laboratory findings, and diagnosis and management of ABPA. It highlights clinical and laboratory clues to differentiate ABPA from cystic fibrosis and asthma, which are challenging given clinical and serologic similarities. A practical diagnostic algorithm and management scheme to aid in the treatment of these patients is outlined.
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Abstract
A new phenotype of asthma has been described recently, namely severe asthma with fungal sensitization (SAFS). SAFS can be conceptualized as a continuum of fungal sensitization, with asthma at one end and allergic bronchopulmonary aspergillosis at the other. It is diagnosed by the presence of severe asthma, fungal sensitization, and exclusion of allergic bronchopulmonary aspergillosis. Because of the paucity of data and ambiguity in diagnostic criteria, SAFS is currently more of a diagnosis of exclusion than a specific entity. Treatment of SAFS initially should be similar to that of severe asthma, including the use of omalizumab. The potential role of itraconazole as a specific therapy in SAFS requires more evidence before it can be incorporated in routine practice. An urgent need exists for data regarding the prevalence, natural history, and clinical relevance of SAFS so that its exact characterization and importance as a specific subtype of asthma can be clearly defined. This review summarizes the current understanding of the pathogenesis, diagnosis, and management of SAFS.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India.
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45
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Agarwal R, Khan A, Aggarwal AN, Gupta D. Link between CFTR mutations and ABPA: a systematic review and meta-analysis. Mycoses 2011; 55:357-65. [PMID: 21999194 DOI: 10.1111/j.1439-0507.2011.02130.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Summary There is a biological plausibility on the link between cystic fibrosis transmembrane conductance regulator (CFTR) mutations and allergic bronchopulmonary aspergillosis (ABPA). The aim of the systematic review was to investigate this link by determining the frequency of CFTR mutations in ABPA. We searched the PubMed and EmBase databases for studies reporting CFTR mutations in ABPA. We pooled the odds ratio (OR) and 95% confidence intervals (CI) from individual studies using both fixed and random effects model. Statistical heterogeneity was evaluated using the I(2) test and the Cochran-Q statistic. Publication bias was assessed using both graphical and statistical methods. Our search yielded four studies (79 ABPA, 268 controls). The odds of encountering CFTR mutation was higher in ABPA compared with the control group (OR 10.39; 95% CI, 4.35-24.79) or the asthma population (OR 5.53; 95% CI 1.62-18.82). There was no evidence of statistical heterogeneity or publication bias. There is a possible pathogenetic link between CFTR mutations and ABPA. However, because of the small numbers of patients, further studies are required to confirm this finding. Future studies should adopt a uniform methodology and should screen for the entire genetic sequence of the CFTR gene.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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46
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Immunopathology and immunogenetics of allergic bronchopulmonary aspergillosis. J Allergy (Cairo) 2011; 2011:785983. [PMID: 21966295 PMCID: PMC3182330 DOI: 10.1155/2011/785983] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 07/14/2011] [Indexed: 11/17/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a Th2 hypersensitivity lung disease in response to Aspergillus fumigatus that affects asthmatic and cystic fibrosis (CF) patients. Sensitization to A. fumigatus is common in both atopic asthmatic and CF patients, yet only 1%–2% of asthmatic and 7%–9% of CF patients develop ABPA. ABPA is characterized by wheezing and pulmonary infiltrates which may lead to pulmonary fibrosis and/or bronchiectasis. The inflammatory response is characterized by Th2 responses to Aspergillus allergens, increased serum IgE, and eosinophilia. A number of genetic risks have recently been identified in the development of ABPA. These include HLA-DR and HLA-DQ, IL-4 receptor alpha chain (IL-4RA) polymorphisms, IL-10 −1082GA promoter polymorphisms, surfactant protein A2 (SP-A2) polymorphisms, and cystic fibrosis transmembrane conductance regulator gene (CFTR) mutations. The studies indicate that ABPA patients are genetically at risk to develop skewed and heightened Th2 responses to A. fumigatus antigens. These genetic risk studies and their consequences of elevated biologic markers may aid in identifying asthmatic and CF patients who are at risk to the development of ABPA. Furthermore, these studies suggest that immune modulation with medications such as anti-IgE, anti-IL-4, and/or IL-13 monoclonal antibodies may be helpful in the treatment of ABPA.
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47
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Allergic bronchopulmonary aspergillosis in asthma and cystic fibrosis. Clin Dev Immunol 2011; 2011:843763. [PMID: 21603163 PMCID: PMC3095475 DOI: 10.1155/2011/843763] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 02/08/2011] [Indexed: 12/18/2022]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a Th2 hypersensitivity lung disease in response to Aspergillus fumigatus that affects asthmatic and cystic fibrosis (CF) patients. Sensitization to A. fumigatus is common in both atopic asthmatic and CF patients, yet only 1-2% of asthmatic and 7-9% of CF patients develop ABPA. ABPA is characterized by wheezing and pulmonary infiltrates which may lead to pulmonary fibrosis and/or bronchiectasis. The inflammatory response is characterized by Th2 responses to Aspergillus allergens, increased serum IgE and eosinophilia. A number of genetic risks have recently been identified in the development of ABPA. These include HLA-DR and HLA-DQ, IL-4 receptor alpha chain (IL-4RA) polymorphisms, IL-10-1082GA promoter polymorphisms, surfactant protein A2 (SP-A2) polymorphisms, and cystic fibrosis transmembrane conductance regulator gene (CFTR) mutations. The studies indicate that ABPA patients are genetically at risk to develop skewed and heightened Th2 responses to A. fumigatus antigens. These genetic risk studies and their consequences of elevated biologic markers may aid in identifying asthmatic and CF patients who are at risk to the development of ABPA. Furthermore, these studies suggest that immune modulation with medications such as anti-IgE, anti-IL-4 and/or IL-13 monoclonal antibodies may be helpful in the treatment of ABPA.
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48
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Goldman DL, Huffnagle GB. Potential contribution of fungal infection and colonization to the development of allergy. Med Mycol 2010; 47:445-56. [PMID: 19384753 DOI: 10.1080/13693780802641904] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Fungi have long been recognized as an important source of allergens in patients with atopic disease. In this review, we explore the hypothesis that fungal exposures resulting in colonization or infection directly influence the tendency of an individual to develop allergic disease. According to this hypothesis, fungal exposures especially those early in life may influence the manner in which the immune response handles subsequent responses to antigen exposures. Studies detailing this potential connection between fungi have already provided important insights into the immunology of fungal-human interactions and offer the potential to provide new approaches and targets for the therapy of allergic disease. The first half of this review summarizes the data concerning fungal infections and asthma, including possible connections between fungal infections and urban asthma. The second half explores the potential role of the fungal gastrointestinal microbiota in promoting allergic inflammation.
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Affiliation(s)
- David L Goldman
- Department of Pediatrics, Childrens' Hospital at Montefiore, Albert Einstein College of Medicine, NY 10461, USA.
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49
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Chaudhary N, Staab JF, Marr KA. Healthy human T-Cell Responses to Aspergillus fumigatus antigens. PLoS One 2010; 5:e9036. [PMID: 20174463 PMCID: PMC2822840 DOI: 10.1371/journal.pone.0009036] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Accepted: 01/15/2010] [Indexed: 11/18/2022] Open
Abstract
Background Aspergillus fumigatus is associated with both invasive and allergic pulmonary diseases, in different hosts. The organism is inhaled as a spore, which, if not cleared from the airway, germinates into hyphal morphotypes that are responsible for tissue invasion and resultant inflammation. Hyphae secrete multiple products that function as antigens, evoking both a protective (TH1–TH17) and destructive allergic (TH2) immunity. How Aspergillus allergens (Asp f proteins) participate in the development of allergic sensitization is unknown. Methodology/Principal Findings To determine whether Asp f proteins are strictly associated with TH2 responses, or represent soluble hyphal products recognized by healthy hosts, human T cell responses to crude and recombinant products were characterized by ELISPOT. While responses (number of spots producing IFN-γ, IL-4 or IL-17) to crude hyphal antigen preparations were weak, responses to recombinant Asp f proteins were higher. Recombinant allergens stimulated cells to produce IFN-γ more so than IL-4 or IL-17. Volunteers exhibited a diverse CD4+ and CD8+ T cell antigen recognition profile, with prominent CD4 TH1-responses to Asp f3 (a putative peroxismal membrane protein), Asp f9/16 (cell wall glucanase), Asp f11 (cyclophilin type peptidyl-prolyl isomerase) and Asp f22 (enolase). Strong IFN-γ responses were reproduced in most subjects tested over 6 month intervals. Conclusions Products secreted after conidial germination into hyphae are differentially recognized by protective T cells in healthy, non-atopic individuals. Defining the specificity of the human T cell repertoire, and identifying factors that govern early responses may allow for development of novel diagnostics and therapeutics for both invasive and allergic Aspergillus diseases.
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Affiliation(s)
- Neelkamal Chaudhary
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Janet F. Staab
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kieren A. Marr
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
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Paveglio SA, Allard J, Foster Hodgkins SR, Ather JL, Bevelander M, Campbell JM, Whittaker LeClair LA, McCarthy SM, van der Vliet A, Suratt BT, Boyson JE, Uematsu S, Akira S, Poynter ME. Airway epithelial indoleamine 2,3-dioxygenase inhibits CD4+ T cells during Aspergillus fumigatus antigen exposure. Am J Respir Cell Mol Biol 2010; 44:11-23. [PMID: 20118221 DOI: 10.1165/rcmb.2009-0167oc] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Indoleamine 2,3-dioxygenase (IDO) suppresses the functions of CD4(+) T cells through its ability to metabolize the essential amino acid tryptophan. Although the activity of IDO is required for the immunosuppression of allergic airway disease by the Toll-Like-Receptor 9 (TLR9) agonist, oligonucleotides comprised of cytosine and guanine nucleotides linked by phosphodiester bonds (CpG) DNA, it is unclear whether IDO expression by resident lung epithelial cells is sufficient to elicit these effects. Therefore, we created a transgenic mouse inducibly overexpressing IDO within nonciliated airway epithelial cells. Upon inhalation of formalin-fixed Aspergillus fumigatus hyphal antigens, the overexpression of IDO from airway epithelial cells of these mice reduced the number of CD4(+) T cells within the inflamed lung and impaired the capacity of antigen-specific splenic CD4(+) effector T cells to secrete the cytokines IL-4, IL-5, IL-13, and IFN-γ. Despite these effects, allergic airway disease pathology was largely unaffected in mice expressing IDO in airway epithelium. In support of the concept that dendritic cells are the major cell type contributing to the IDO-inducing effects of CpG DNA, mice expressing TLR9 only in the airway epithelium did not augment IDO expression subsequent to the administration of CpG DNA. Furthermore, the systemic depletion of CD11c(+) cells rendered mice incapable of CpG DNA-induced IDO expression. Our results demonstrate that an overexpression of IDO within the airway epithelium represents a novel mechanism by which the number of CD4(+) T cells recruited to the lung and their capacity to produce cytokines can be diminished in a model of allergic airway disease, and these results also highlight the critical role of dendritic cells in the antiasthmatic effects of IDO induction by CpG DNA.
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Affiliation(s)
- Sara A Paveglio
- Vermont Lung Center, and Division of Pulmonary Disease and Critical Care, Department of Medicine, University of Vermont, 149 Beaumont Ave., Burlington, VT 05405, USA
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