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Chatterjee P, Moss CT, Omar S, Dhillon E, Hernandez Borges CD, Tang AC, Stevens DA, Hsu JL. Allergic Bronchopulmonary Aspergillosis (ABPA) in the Era of Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulators. J Fungi (Basel) 2024; 10:656. [PMID: 39330416 PMCID: PMC11433030 DOI: 10.3390/jof10090656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 09/11/2024] [Accepted: 09/13/2024] [Indexed: 09/28/2024] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disease caused by Aspergillus fumigatus (Af), prevalent in persons with cystic fibrosis (CF) or asthma. In ABPA, Af proteases drive a T-helper cell-2 (Th2)-mediated allergic immune response leading to inflammation that contributes to permanent lung damage. Corticosteroids and antifungals are the mainstays of therapies for ABPA. However, their long-term use has negative sequelae. The treatment of patients with CF (pwCF) has been revolutionized by the efficacy of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy. Pharmacological improvement in CFTR function with highly effective elexacaftor/tezacaftor/ivacaftor (ETI) provides unprecedented improvements in lung function and other clinical outcomes of pwCF. The mechanism behind the improvement in patient outcomes is a continued topic of investigation as our understanding of the role of CFTR function evolves. As ETI therapy gains traction in CF management, understanding its potential impact on ABPA, especially on the allergic immune response pathways and Af infection becomes increasingly crucial for optimizing patient outcomes. This literature review aims to examine the extent of these findings and expand our understanding of the already published research focusing on the intersection between ABPA therapeutic approaches in CF and the rapid impact of the evolving CFTR modulator landscape. While our literature search yielded limited reports specifically focusing on the role of CFTR modulator therapy on CF-ABPA, findings from epidemiologic and retrospective studies suggest the potential for CFTR modulator therapies to positively influence pulmonary outcomes by addressing the underlying pathophysiology of CF-ABPA, especially by decreasing inflammatory response and Af colonization. Thus, this review highlights the promising scope of CFTR modulator therapy in decreasing the overall prevalence and incidence of CF-ABPA.
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Affiliation(s)
- Paulami Chatterjee
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (P.C.); (S.O.); (E.D.)
| | - Carson Tyler Moss
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Sarah Omar
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (P.C.); (S.O.); (E.D.)
| | - Ekroop Dhillon
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (P.C.); (S.O.); (E.D.)
| | | | - Alan C. Tang
- Department of Medicine, Keck School of Medicine, Los Angeles, CA 90089, USA;
| | - David A. Stevens
- Division of Infectious Diseases and Geographic Medicine, Stanford University Medical School, Stanford, CA 94305, USA;
| | - Joe L. Hsu
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (P.C.); (S.O.); (E.D.)
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Simmonds NJ, Southern KW, De Wachter E, De Boeck K, Bodewes F, Mainz JG, Middleton PG, Schwarz C, Vloeberghs V, Wilschanski M, Bourrat E, Chalmers JD, Ooi CY, Debray D, Downey DG, Eschenhagen P, Girodon E, Hickman G, Koitschev A, Nazareth D, Nick JA, Peckham D, VanDevanter D, Raynal C, Scheers I, Waller MD, Sermet-Gaudelus I, Castellani C. ECFS standards of care on CFTR-related disorders: Identification and care of the disorders. J Cyst Fibros 2024; 23:590-602. [PMID: 38508949 DOI: 10.1016/j.jcf.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/06/2024] [Accepted: 03/08/2024] [Indexed: 03/22/2024]
Abstract
This is the third paper in the series providing updated information and recommendations for people with cystic fibrosis transmembrane conductance regulator (CFTR)-related disorder (CFTR-RD). This paper covers the individual disorders, including the established conditions - congenital absence of the vas deferens (CAVD), diffuse bronchiectasis and chronic or acute recurrent pancreatitis - and also other conditions which might be considered a CFTR-RD, including allergic bronchopulmonary aspergillosis, chronic rhinosinusitis, primary sclerosing cholangitis and aquagenic wrinkling. The CFTR functional and genetic evidence in support of the condition being a CFTR-RD are discussed and guidance for reaching the diagnosis, including alternative conditions to consider and management recommendations, is provided. Gaps in our knowledge, particularly of the emerging conditions, and future areas of research, including the role of CFTR modulators, are highlighted.
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Affiliation(s)
- N J Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, UK.
| | - K W Southern
- Department of Women's and Children's Health, University of Liverpool, University of Liverpool, Alder Hey Children's Hospital, Liverpool, UK
| | - E De Wachter
- Cystic Fibrosis Center, Pediatric Pulmonology department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - K De Boeck
- Department of Pediatrics, University of Leuven, Leuven, Belgium
| | - F Bodewes
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Groningen Medical Center, Groningen, the Netherlands
| | - J G Mainz
- Cystic Fibrosis Center, Brandenburg Medical School (MHB), University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - P G Middleton
- Cystic Fibrosis and Bronchiectasis Service, Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, News South Wales, Australia
| | - C Schwarz
- HMU-Health and Medical University Potsdam, CF Center Westbrandenburg, Campus Potsdam, Germany
| | - V Vloeberghs
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - M Wilschanski
- CF Center, Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - E Bourrat
- APHP, Service de Dermatologie, CRMR MAGEC Nord St Louis, Hôpital-Saint Louis, Paris, France
| | - J D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - C Y Ooi
- a) School of Clinical Medicine, Discipline of Paediatrics and Child Health, Medicine & Health, University of New South Wales, Level 8, Centre for Child Health Research & Innovation Bright Alliance Building Cnr Avoca & High Streets, Randwick, Sydney, NSW, Australia, 2031; b) Sydney Children's Hospital, Gastroenterology Department, High Street, Randwick, Sydney, NSW, Australia, 2031
| | - D Debray
- Pediatric Hepatology unit, Centre de Référence Maladies Rares (CRMR) de l'atrésie des voies biliaires et cholestases génétiques (AVB-CG), National network for rare liver diseases (Filfoie), ERN rare liver, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - D G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | - E Girodon
- Service de Médecine Génomique des Maladies de Système et d'Organe, APHP.Centre - Université de Paris Cité, Hôpital Cochin, Paris, France
| | - G Hickman
- APHP, Service de Dermatologie, CRMR MAGEC Nord St Louis, Hôpital-Saint Louis, Paris, France
| | - A Koitschev
- Klinikum Stuttgart, Pediatric Otorhinolaryngology, Stuttgart, Germany
| | - D Nazareth
- a) Adult CF Unit, Liverpool Heart and Chest Hospital NHS Foundation Trust, U.K; b) Clinical Infection, Microbiology and Immunology, University of Liverpool, UK
| | - J A Nick
- Department of Medicine, National Jewish Health, Denver, CO, 80206, USA, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - D Peckham
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - D VanDevanter
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - C Raynal
- Laboratory of molecular genetics, University Hospital of Montpellier and INSERM U1046 PHYMEDEXP, Montpellier, France
| | - I Scheers
- Department of Pediatrics, Pediatric Gastroenterology and Hepatology Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - M D Waller
- Adult Cystic Fibrosis and Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; Honorary Senior Lecturer, King's College London, London, United Kingdom
| | - I Sermet-Gaudelus
- INSERM U1151, Institut Necker Enfants Malades, Paris, France; Université de Paris, Paris, France; Centre de référence Maladies Rares, Mucoviscidose et maladies apparentées, Hôpital Necker Enfants malades, Paris, France
| | - C Castellani
- IRCCS Istituto Giannina Gaslini, Cystic Fibrosis Center, Genoa, Italy
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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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Abstract
In cystic fibrosis, a new era has started with the approval and use of highly effective cystic fibrosis transport regulator (CFTR) modulator therapy. As pulmonary function is increasing and exacerbation rate significantly decreases, the current meaning of fungal pulmonary diseases is questioned. During the past couple of decades, several studies have been conducted regarding fungal colonization and infection of the airways in people with cystic fibrosis. Although Aspergillus fumigatus for filamentous fungi and Candida albicans for yeasts remain by far the most common fungal species in patients with cystic fibrosis, the pattern of fungal species associated with cystic fibrosis has considerably diversified recently. Fungi such as Scedosporium apiospermum or Exophiala dermatitidis are recognized as pathogenic in cystic fibrosis and therefore need attention in clinical settings. In this article, current definitions are stated. Important diagnostic steps are described, and their usefulness discussed. Furthermore, clinical treatment strategies and recommendations are named and evaluated. In cystic fibrosis, fungal entities can be divided into different subgroups. Besides colonization, allergic bronchopulmonary aspergillosis, bronchitis, sensitization, pneumonia, and aspergilloma can occur as a fungal disease entity. For allergic bronchopulmonary aspergillosis, bronchitis, pneumonia, and aspergilloma, clear indications for therapy exist but this is not the case for sensitization or colonization. Different pulmonary fungal disease entities in people with cystic fibrosis will continue to occur also in an era of highly effective CFTR modulator therapy. Whether the percentage will decrease or not will be the task of future evaluations in studies and registry analysis. Using the established definition for different categories of fungal diseases is recommended and should be taken into account if patients are deteriorating without responding to antibiotic treatment. Drug-drug interactions, in particular when using azoles, should be recognized and therapies need to be adjusted accordingly.
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Affiliation(s)
- Carsten Schwarz
- Department of Education and Research, Health and Medical University-Health and Medical University Potsdam, Potsdam, Germany.,Division of Cystic Fibrosis, Cystic Fibrosis Center West Brandenburg, Postdam, Germany
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Steels S, Proesmans M, Bossuyt X, Dupont L, Frans G. Laboratory biomarkers in the diagnosis and follow-up of treatment of allergic bronchopulmonary aspergillosis in cystic fibrosis. Crit Rev Clin Lab Sci 2023; 60:1-24. [PMID: 35968577 DOI: 10.1080/10408363.2022.2101612] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA), a severe inflammatory respiratory disease, is caused by a hypersensitivity reaction to the colonization of the airways with Aspergillus fumigatus. It is most often described in patients with asthma or cystic fibrosis. The diagnosis of ABPA is based on a combination of clinical, radiological, and immunological findings that have been included in different diagnostic criteria over the years. In this paper, we review the biomarkers included in these diagnostic criteria and novel research biomarkers that may be used in the diagnosis and treatment follow-up of ABPA in cystic fibrosis.
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Affiliation(s)
- Sophie Steels
- Department of Laboratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marijke Proesmans
- Department of Pediatrics, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Xavier Bossuyt
- Department of Laboratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Clinical and Diagnostic Immunology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Lieven Dupont
- Department of Respiratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Glynis Frans
- Department of Laboratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Francis NZ, Southern KW. Antifungal therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2022; 9:CD002204. [PMID: 36053129 PMCID: PMC9438469 DOI: 10.1002/14651858.cd002204.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is an allergic reaction to colonisation of the lungs with the fungus Aspergillus fumigatus, and affects around 10% of people with cystic fibrosis. ABPA is associated with an accelerated decline in lung function. High doses of corticosteroids are the main treatment for ABPA; although the long-term benefits are not clear, and their many side effects are well-documented. A group of compounds, the azoles, have activity against A fumigatus, and have been proposed as an alternative treatment for ABPA. Of this group, itraconazole is the most active. A separate antifungal compound, amphotericin B, has been used in aerosolised form to treat invasive infection with A fumigatus, and may have potential for the treatment of ABPA. Antifungal therapy for ABPA in cystic fibrosis needs to be evaluated. This is an update of a previously published review. OBJECTIVES The review aimed to test the hypotheses that antifungal interventions for the treatment of ABPA in cystic fibrosis: 1. improve clinical status compared to placebo or standard therapy (no placebo); and 2. do not have unacceptable adverse effects. If benefit was demonstrated, we planned to assess the optimal type, duration, and dose of antifungal therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals, and abstract books of conference proceedings. Date of the most recent search of the Group's Trials Register was 28 September 2021. We searched ongoing trials registries, most recently on 11 March 2022. Earlier, we also approached pharmaceutical companies regarding possible unpublished trials. SELECTION CRITERIA Published or unpublished randomised controlled trials, in which antifungal treatments were compared to either placebo or no treatment, or where different doses of the same treatment were used in the treatment of ABPA in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS The searches identified six trials; none of which met the inclusion criteria for the review. MAIN RESULTS We included no completed randomised controlled trials. There is currently one ongoing trial, which we may find eligible for a future update. AUTHORS' CONCLUSIONS At present, there are no randomised controlled trials that evaluate the use of antifungal therapies for the treatment of ABPA in people with cystic fibrosis, although one trial is currently ongoing. Trials with clear outcome measures are needed to properly evaluate the use of corticosteroids in people with ABPA and cystic fibrosis.
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Affiliation(s)
- Natalie Z Francis
- Manchester Adult Cystic Fibrosis Centre, University of Manchester, Manchester, UK
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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Clinical Impact of Aspergillus fumigatus in Children with Cystic Fibrosis. Microorganisms 2022; 10:microorganisms10040739. [PMID: 35456789 PMCID: PMC9032721 DOI: 10.3390/microorganisms10040739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background. The clinical relevance of Aspergillus fumigatus (Af) in cystic fibrosis (CF) is controversial. The aims of the study were to assess the prevalence of Af disease in our cohort of CF patients and evaluate whether allergic bronchopulmonary aspergillosis (ABPA) and sensitization to Af affected lung function, body mass index (BMI) and exacerbations. Methods. Clinical data and lung function of CF patients aged 6−18 years followed at the CF Centre of Parma (Italy) were recorded. Patients were classified as: patients with no signs of Af, patients sensitized or colonized by Af, patients with ABPA or patients with Aspergillus bronchitis (Ab). Results. Of 38 CF patients (14.2 years (6.2−18.8) M 23), 8 (21%) showed Af sensitization, 7 (18.4%) showed ABPA, 1 (2.6%) showed Af colonization and 1 (2.6%) showed Ab. Compared to non-ABPA, patients with ABPA had lower BMI (15.9 ± 1.6 vs. 19.7 ± 3.4, p < 0.005), lower lung function (FEV1 61.5 ± 25.9% vs. 92.3 ± 19.3%, p < 0.001) and more exacerbations/year (4.43 ± 2.44 vs. 1.74 ± 2.33, p < 0.005). Patients with Af sensitization showed more exacerbations/year than non-Af patients (3.5 ± 3.2 vs. 0.9 ± 1.2, p < 0.005). ABPA and sensitized patients had more abnormalities on chest CT scans. Conclusion. This study showed the relevant clinical impact of ABPA and Af sensitization in terms of exacerbations and lung structural damage.
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Agarwal R, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Aggarwal AN. Allergic Bronchopulmonary Aspergillosis. Clin Chest Med 2022; 43:99-125. [DOI: 10.1016/j.ccm.2021.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Jat KR, Walia DK, Khairwa A. Anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2021; 9:CD010288. [PMID: 34550603 PMCID: PMC8457344 DOI: 10.1002/14651858.cd010288.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive multisystem disorder with an approximate prevalence of 1 in 3500 live births. Allergic bronchopulmonary aspergillosis is a lung disease caused by aspergillus-induced hypersensitivity with a prevalence of 2% to 15% in people with cystic fibrosis. The mainstay of treatment includes corticosteroids and itraconazole. The treatment with corticosteroids for prolonged periods of time, or repeatedly for exacerbations of allergic bronchopulmonary aspergillosis, may lead to many adverse effects. The monoclonal anti-IgE antibody, omalizumab, has improved asthma control in severely allergic asthmatics. The drug is given as a subcutaneous injection every two to four weeks. Since allergic bronchopulmonary aspergillosis is also a condition resulting from hypersensitivity to specific allergens, as in asthma, it may be a candidate for therapy using anti-IgE antibodies. Therefore, anti-IgE therapy, using agents like omalizumab, may be a potential therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. This is an updated version of the review. OBJECTIVES To evaluate the efficacy and adverse effects of anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Last search: 09 September 2021. We searched two ongoing trial registries (Clinicaltrials.gov and the WHO trials platform). Date of latest search: 16 August 2021. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing anti-IgE therapy to placebo or other therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias in the included study. They planned to perform data analysis using Review Manager. MAIN RESULTS Only one study enrolling 14 participants was eligible for inclusion in the review. The double-blind study compared a daily dose of 600 mg omalizumab or placebo along with twice daily itraconazole and oral corticosteroids, with a maximum daily dose of 400 mg. Treatment lasted six months but the study was terminated prematurely and complete data were not available. We contacted the study investigator and were told that the study was terminated due to the inability to recruit participants into the study despite all reasonable attempts. One or more serious side effects were encountered in six out of nine (66.67%) and one out of five (20%) participants in omalizumab group and placebo group respectively. AUTHORS' CONCLUSIONS There is lack of evidence for the efficacy and safety of anti-IgE (omalizumab) therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis. There is a need for large prospective randomized controlled studies of anti-IgE therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis with both clinical and laboratory outcome measures such as steroid requirement, allergic bronchopulmonary aspergillosis exacerbations and lung function.
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Affiliation(s)
- Kana R Jat
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Dinesh K Walia
- Department of Community Medicine, Govt. Medical College and Hospital (GMCH), Chandigarh, India
| | - Anju Khairwa
- Department of Pathology, University College of Medical Sciences (UCMS), Delhi, India
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Hughes DA, Archangelidi O, Coates M, Armstrong-James D, Elborn SJ, Carr SB, Davies JC. Clinical characteristics of Pseudomonas and Aspergillus co-infected cystic fibrosis patients: A UK registry study. J Cyst Fibros 2021; 21:129-135. [PMID: 33958279 DOI: 10.1016/j.jcf.2021.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pseudomonas aeruginosa (Pa) and Aspergillus species (Asp) are the most common bacterial and fungal organisms respectively in CF airways. Our aim was to examine impacts of Asp infection and Pa/Asp co-infection. METHODS Patients on the UK CF Registry in 2016 were grouped into: absent (Pa-), intermittent (Pai) or chronic Pa (Pac), each with Asp positive (Asp+) or negative (Asp-). Primary outcome was best percentage predicted FEV1 (ppFEV1) that year. Secondary outcomes were intravenous (IV) antibiotic courses, growth (height, weight, BMI) and additional disease complications. Associations between outcomes and infection-status were assessed using regression models adjusting for significant confounders (age, sex, Phe508del homozygosity and CF-related diabetes (CFRD)). RESULTS 9,270 patients were included (median age 19 [IQR 9-30] years, 54% male, 50% Phe508del/F508del). 4,142 patients (45%) isolated Pa, 1,460 (16%) Asp. Pa-/Asp+ subjects had an adjusted ppFEV1 that was 5.9% lower than Pa-/Asp- (p < 0.0001). In patients with Pai or Pac, there was no additional impact of Asp on ppFEV1. However, there was a higher probability that Pac/Asp+ patients had required IV antibiotics than Pac/Asp- group (OR 1.23 [1.03-1.48]). Low BMI, ABPA, CF-liver disease and CFRD were all more frequent with Asp alone than Pa-/Asp-, though not more common in Pac/Asp+ than Pac/Asp-. CONCLUSIONS Co-infection with Pa and Asp was not associated with reduced lung function compared with Pa alone, but was associated with additional use of IV antibiotics. Asp infection itself is associated with several important indicators of disease severity. Longitudinal analyses should explore the impact of co-infection on disease progression.
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Affiliation(s)
- Dominic A Hughes
- National Heart & Lung Institute, Imperial College London, UK; Royal Brompton and Harefield Hospitals, London, UK.
| | | | - Matthew Coates
- National Heart & Lung Institute, Imperial College London, UK
| | - Darius Armstrong-James
- Royal Brompton and Harefield Hospitals, London, UK; Department of Infectious Diseases, Imperial College London, UK
| | | | - Siobhán B Carr
- National Heart & Lung Institute, Imperial College London, UK; Royal Brompton and Harefield Hospitals, London, UK
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, UK; Royal Brompton and Harefield Hospitals, London, UK
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11
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Konstan MW, Pasta DJ, VanDevanter DR, Wagener JS, Morgan WJ. Epidemiologic Study of Cystic Fibrosis: 25 years of observational research. Pediatr Pulmonol 2021; 56:823-836. [PMID: 33434406 PMCID: PMC9123916 DOI: 10.1002/ppul.25248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/19/2020] [Accepted: 12/25/2020] [Indexed: 11/09/2022]
Abstract
The Epidemiologic Study of Cystic Fibrosis (ESCF) was a prospective observational study of over 32,000 people with cystic fibrosis (CF) from 250 clinical care sites in North America from 1994 to 2005. Begun as a pharmacovigilance study in connection with the approval of dornase alfa in 1993, ESCF was open to all people with CF treated at any participating site in the United States or Canada. In addition to obtaining safety and effectiveness data on dornase alfa, ESCF collected encounter-based data to characterize the natural history and management of CF with a special focus on lung disease. During the study, 32,178 patients reported at least one encounter, contributing 869,136 encounters, 622,592 pulmonary function tests, 432,896 cultures, and 118,563 pulmonary exacerbations treated with intravenous antibiotics. Although ESCF data collection concluded in 2005, through a collaboration with the U.S. Cystic Fibrosis Foundation Patient Registry, additional follow-up data through 2017 was available for two-thirds of patients. This allowed for updating of CF genotype and survival information. Fifty-six peer-reviewed publications (cited over 3600 times) resulted from this study. In this manuscript we summarize the published ESCF manuscripts in thematic groups with key study findings and brief comments, and speculate on how ESCF findings will inform future data registries and patient care practices.
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Affiliation(s)
- Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | | | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Jeffrey S Wagener
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA
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12
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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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Iwahashi J, Kamei K, Watanabe H. Disruption of Aspergillus fumigatus biofilm by Streptococcus pneumoniae: Mycelial fragmentation by hydrogen peroxide. J Infect Chemother 2020; 26:831-837. [PMID: 32414689 DOI: 10.1016/j.jiac.2020.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/07/2020] [Accepted: 03/24/2020] [Indexed: 01/06/2023]
Abstract
Biofilm is a complex structure consisting of microorganisms such as bacteria, fungi and an extracellular matrix (ECM). Biofilms are involved in most microbial infections and show persistent resistance to antibiotic treatment and immune response. Both Aspergillus fumigatus and Streptococcus pneumoniae are colonizers that can form biofilms in the respiratory tract. These pathogens have been simultaneously isolated from the same patient, but their interaction is poorly understood. We observed morphological changes in single- and mixed-species biofilms prepared for confocal laser scanning microscopy and scanning electron microscopy (SEM). Pneumococci suppressed the development of a fungal biofilm, and it even disrupted a preformed fungal biofilm. When a preformed fungal biofilm was treated with pneumococci, the mycelial network was fragmented, and only bacteria could develop. SEM revealed that the fragmented mycelium was further disrupted into fine filaments as treatment time progressed, and that the ECM of the preformed fungal biofilm had disappeared. The pneumococcal culture supernatant contained mycelial fragmentation activity that was heat-sensitive. The culture supernatant of a mutant pneumococcal strain deficient in pneumolysin (Δply) also exhibited the mycelial fragmentation activity. Enolase and lactate oxidase, which are involved in glycolysis and hydrogen peroxide production, were identified in the culture supernatant of the Δply mutant. Neither the wild type nor the mutant strain could fragment the mycelium in the presence of catalase. These data suggest that hydrogen peroxide could fragment the mycelium and would terminate the co-existence of A. fumigatus and S. pneumoniae in biofilm.
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Affiliation(s)
- Jun Iwahashi
- Department of Infection Control and Prevention, Kurume University School of Medicine, 67 Asahi-machi, Kurume City, Fukuoka 830-0011, Japan.
| | - Katsuhiko Kamei
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8673, Japan
| | - Hiroshi Watanabe
- Department of Infection Control and Prevention, Kurume University School of Medicine, 67 Asahi-machi, Kurume City, Fukuoka 830-0011, Japan
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Tomomatsu K, Oguma T, Baba T, Toyoshima M, Komase Y, Taniguchi M, Asano K. Effectiveness and Safety of Omalizumab in Patients with Allergic Bronchopulmonary Aspergillosis Complicated by Chronic Bacterial Infection in the Airways. Int Arch Allergy Immunol 2020; 181:499-506. [PMID: 32388510 DOI: 10.1159/000507216] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/13/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) develops in the presence of predisposing conditions such as asthma and cystic fibrosis. Even ABPA accompanied by asthma is often complicated by chronic Pseudomonas aeruginosa or nontuberculous mycobacterial infection of the lower respiratory tract, rendering treatment with corticosteroids difficult. There have been several reports on the effectiveness of omalizumab, an anti-IgE antibody, in patients with ABPA. We analyzed the effectiveness and adverse effects of omalizumab in ABPA patients with chronic respiratory infections. METHODS Using our nationwide survey database and published case reports, we identified patients with severe asthma and ABPA who fulfilled the International Society for Human and Animal Mycology criteria and who had been treated with omalizumab. Exacerbation rates, control of symptoms, doses of oral corticosteroids, and pulmonary function were evaluated. RESULTS Among 25 patients with ABPA treated with omalizumab (median age 62 years, range 33-83 years), 12 patients had a chronic bacterial infection of the lower airways attributable to P. aeruginosa (n = 6) or nontuberculous mycobacteria (n = 6) at the initiation of omaliz-umab. Treatment with omalizumab reduced the frequency of exacerbations and systemic corticosteroid doses and improved pulmonary function. There were no significant adverse events or worsening of infection during treatment with omalizumab, except for injection-site reactions. CONCLUSIONS Treatment with omalizumab was effective and safe in patients with ABPA, regardless of comorbid chronic respiratory tract infections.
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Affiliation(s)
- Katsuyoshi Tomomatsu
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Tsuyoshi Oguma
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Kanagawa, Japan
| | - Mikio Toyoshima
- Department of Respiratory Medicine, Hamamatsu Rosai Hospital, Shizuoka, Japan
| | - Yuko Komase
- Department of Respiratory Medicine, Yokohama-City Seibu Hospital, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masami Taniguchi
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan,
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Pollak M, Shaw M, Wilson D, Grasemann H, Ratjen F. Bronchodilator responsiveness in children with cystic fibrosis and allergic bronchopulmonary aspergillosis. Eur Respir J 2020; 56:13993003.00175-2020. [DOI: 10.1183/13993003.00175-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/31/2020] [Indexed: 12/26/2022]
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Fungal Infections and ABPA. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_6] [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: 10/24/2022]
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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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Keown K, Abbott S, Kuzeljevic B, Rayment JH, Chilvers MA, Yang CL. An investigation into biomarkers for the diagnosis of ABPA and aspergillus disease in cystic fibrosis. Pediatr Pulmonol 2019; 54:1787-1793. [PMID: 31359612 DOI: 10.1002/ppul.24465] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/25/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity lung disease due to Aspergillus fumigatus (Af) which occurs in 10% of patients with cystic fibrosis (CF). ABPA is associated with increased morbidity and accelerated lung function decline; however, existing diagnostic criteria are nonspecific and diagnosis remains challenging. As ABPA is driven by Th2 inflammation, the aim of this study was to evaluate exhaled nitric oxide (FE NO ), eosinophilic cationic protein (ECP), peripheral eosinophil count, and bronchodilator response (BDR) in patients with CF. METHODS A prospective observational cohort study of pediatric CF patients in a tertiary center. Patients had a clinical and serologic ABPA assessment, FENO , serum ECP, peripheral eosinophil count, and assessment of BDR. Patients were stratified into three groups; ABPA, Af sensitized (AFS), and non-ABPA non-Af-sensitized (non-AFS). RESULTS A total of 62 patients were included in the study: 13% ABPA, 19% AFS, and 68% non-AFS. Mean FENO was higher in the ABPA group at 37.8 ppb compared to AFS 15.1 ppb (P = .05) and non-AFS 13.7 ppb (P = .04). Mean peripheral eosinophil count in ABPA group was also higher at 1000 cells/uL, compared to AFS 221 cells/uL (P = .03) and non-AFS 220 cells/uL (P = .03). Mean BDR in ABPA group was 13% compared to 5.5% in non-AFS (P = .01). Serum ECP was higher in patients with ABPA positive compared to the other groups, although this was not statistically significant. CONCLUSION In children with cystic fibrosis, FENO and peripheral eosinophil counts are elevated in ABPA compared to those that are just sensitized to Aspergillus and may serve as useful diagnostic tests.
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Affiliation(s)
- Karen Keown
- Division of Respiratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Salome Abbott
- Division of Respiratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Boris Kuzeljevic
- Division of Respiratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Jonathan H Rayment
- Division of Respiratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Mark A Chilvers
- Division of Respiratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Connie L Yang
- Division of Respiratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
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McGarry ME, Neuhaus JM, Nielson DW, Ly NP. Regional variations in longitudinal pulmonary function: A comparison of Hispanic and non-Hispanic subjects with cystic fibrosis in the United States. Pediatr Pulmonol 2019; 54:1382-1390. [PMID: 31144477 PMCID: PMC6702095 DOI: 10.1002/ppul.24377] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 05/08/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hispanic subjects with cystic fibrosis (CF) have increased morbidity and mortality than non-Hispanic white subjects. The ethnic disparity in mortality varies by region. Factors influencing pulmonary function vary by both ethnicity and region. OBJECTIVE To determine if the ethnic difference in pulmonary function varies by region. METHODS This retrospective cohort study compared differences in longitudinal pulmonary function (percent-predicted forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1 ], forced expiratory flow at 25% to 75% [FEF25-75 ], FEV1 /FVC, and FEV1 decline) between Hispanic and non-Hispanic white subjects with CF by Census region of the United States (West, South, Midwest, and Northeast). Subjects were of ages 6 to 25 years and in the CF Foundation Patient Registry from 2008 to 2013. We used linear mixed effects models with subject-specific slopes and intercepts, adjusting for 14 demographic and clinical variables. RESULTS Of 14 932 subjects, 1433 (9.6%) were Hispanic and 13 499 (90.4%) were non-Hispanic white. Hispanic subjects' FEV1 was 9.0% (8.3%-9.8%) lower than non-Hispanic white subjects in the West, while Hispanic subjects' FEV1 was only 4.0% (3.0%-5.0%) lower in the Midwest, 4.4% (3.1%-5.7%) lower in the Northeast, and 4.4% (3.2%-5.5%) lower in the South. Similarly, FVC and FEF25-75 were lower among Hispanic subjects compared to non-Hispanic white subjects in all US regions, with the biggest differences in the West. Only in the West was FEV1 /FVC significantly lower in Hispanic subjects (-0.019; -0.022 to -0.015). FEV1 decline was not significantly different between ethnicities in any region. CONCLUSIONS In CF, Hispanic subjects have lower pulmonary function than non-Hispanic white subjects in all geographic regions with the largest difference in occurring in the West.
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Affiliation(s)
- Meghan E McGarry
- Department of Pediatrics, University of California, San Francisco, California
| | - John M Neuhaus
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Dennis W Nielson
- Department of Pediatrics, University of California, San Francisco, California
| | - Ngoc P Ly
- Department of Pediatrics, University of California, San Francisco, California
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Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Diagnosing Allergic Bronchopulmonary Aspergillosis: A Review. Cureus 2019; 11:e4550. [PMID: 31275774 PMCID: PMC6592842 DOI: 10.7759/cureus.4550] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Dr. Hinson and his colleagues first described allergic bronchopulmonary aspergillosis (ABPA) in 1952. Later in 1977, Rosenberg proposed a diagnostic criteria for ABPA that even today remains widely acknowledged. Despite these steps taken, there still isn't a standardized diagnostic criteria set for ABPA although many have been proposed by various physicians over the years. ABPA is a condition caused by hypersensitivity to Aspergillus fumigatus antigens. It is seen most commonly in patients with either asthma or cystic fibrosis. In susceptible hosts, repeated inhalation of Aspergillus spores can cause an allergic response. Although a standardized diagnostic criteria is required, there is no single test that establishes the diagnosis other than a demonstration of central bronchiectasis (CB) with normal tapering bronchi, a feature that is still considered pathognomonic of ABPA. Because of lack of standardized diagnostic criteria and screening, even today ABPA is under diagnosed and often times treatment for it is delayed. This can lead to complications in patients like pulmonary fibrosis, bronchiectasis with chronic sputum production, and increasingly severe persistent asthma with loss of lung function. For this alone, it becomes imperative that the diagnostic criteria guidelines need to be reviewed and standardized preferably with the help of larger research studies. In the following review article, we address the epidemiology, pathophysiology, and the current cumulative view regarding the diagnosis of ABPA.
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Affiliation(s)
- Avani R Patel
- Internal Medicine, Northern California Kaiser Permanente, Fremont, USA
| | - Amar R Patel
- Internal Medicine, Northern California Kaiser Permanente, Fremont, USA
| | - Shivank Singh
- Internal Medicine, Southern Medical University, Guangzhou, CHN
| | - Shantanu Singh
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
| | - Imran Khawaja
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
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Jat KR, Walia DK, Khairwa A. Anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2018; 3:CD010288. [PMID: 29551015 PMCID: PMC6494205 DOI: 10.1002/14651858.cd010288.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive multisystem disorder with an approximate prevalence of 1 in 3500 live births. Allergic bronchopulmonary aspergillosis is a lung disease caused by aspergillus-induced hypersensitivity with a prevalence of 2% to 15% in people with cystic fibrosis. The mainstay of treatment includes corticosteroids and itraconazole. The treatment with corticosteroids for prolonged periods of time, or repeatedly for exacerbations of allergic bronchopulmonary aspergillosis, may lead to many adverse effects. The monoclonal anti-IgE antibody, omalizumab, has improved asthma control in severely allergic asthmatics. The drug is given as a subcutaneous injection every two to four weeks. Since allergic bronchopulmonary aspergillosis is also a condition resulting from hypersensitivity to specific allergens, as in asthma, it may be a candidate for therapy using anti-IgE antibodies. Therefore, anti-IgE therapy, using agents like omalizumab, may be a potential therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. This is an updated version of the review. OBJECTIVES To evaluate the efficacy and adverse effects of anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Last search: 29 September 2017.We searched two ongoing trial registries (Clinicaltrials.gov and the WHO trials platform). Date of latest search: 24 January 2018. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing anti-IgE therapy to placebo or other therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias in the included study. They planned to perform data analysis using Review Manager. MAIN RESULTS Only one study enrolling 14 participants was eligible for inclusion in the review. The double-blind study compared a daily dose of 600 mg omalizumab or placebo along with twice daily itraconazole and oral corticosteroids, with a maximum daily dose of 400 mg. Treatment lasted six months but the study was terminated prematurely and complete data were not available. We contacted the study investigator and were told that the study was terminated due to the inability to recruit participants into the study despite all reasonable attempts. One or more serious side effects were encountered in six out of nine (66.67%) and one out of five (20%) participants in omalizumab group and placebo group respectively. AUTHORS' CONCLUSIONS There is lack of evidence for the efficacy and safety of anti-IgE (omalizumab) therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis. There is a need for large prospective randomized controlled studies of anti-IgE therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis with both clinical and laboratory outcome measures such as steroid requirement, allergic bronchopulmonary aspergillosis exacerbations and lung function.
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Affiliation(s)
- Kana R Jat
- All India Institute of Medical Sciences (AIIMS)Department of PediatricsAnsari NagarNew DelhiDelhiIndia110029
| | - Dinesh K Walia
- Govt. Medical College and Hospital (GMCH)Department of Community MedicineSector‐32ChandigarhChandigarh UTIndia160030
| | - Anju Khairwa
- Postgraduate Institute of Medical Education and Research (PGIMER)Department of PathologySector‐12ChandigarhChandigarh UTIndia160012
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Alyasin S, Moghtaderi M, Farjadian S, Babaei M, Teshnizi SH. Allergic bronchopulmonary aspergillosis in patients with cystic fibrosis and non-cystic fibrosis bronchiectasis. Electron Physician 2018; 10:6273-6278. [PMID: 29588830 PMCID: PMC5854004 DOI: 10.19082/6273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 08/26/2017] [Indexed: 11/20/2022] Open
Abstract
Background Aspergillus sensitization (AS) and allergic bronchopulmonary aspergillosis (ABPA) can occur as a cause of permanent lung damage in patients with cystic fibrosis (CF) and non-CF bronchiectasis. Objective The aim of this study was to determine the frequency of AS and ABPA in patients with CF and non-CF bronchiectasis in southwestern Iran. Methods This cross-sectional study was conducted on 33 patients with CF and 27 patients with non-CF bronchiectasis from southwestern Iran who were referred to Namazi Hospital affiliated to Shiraz University of Medical Sciences from July 2015 to February 2016. Skin prick test to Aspergillus fumigatus, peripheral blood eosinophil count, total serum IgE, specific IgE and IgG against Aspergillus fumigatus as well as radiologic chest studies were done for each patient. Statistical analysis was done by Mann-Whitney U test, Fisher Exact test, and Kappa weighted in SPSS software version 18. Level of significance was set at p<0.05. Results Nine patients with CF (27.3%) and one patient with non-CF bronchiectasis (3.7%) had positive skin tests to Aspergillus. There was 81.2% agreement between positive skin test and specific IgE to Aspergillus fumigatus (p<0.001). Three patients with CF (9%) met the diagnostic criteria for ABPA, whereas ABPA was not seen in patients with non-CF bronchiectasis. Conclusion ABPA was low in this study, considering more frequency of AS in patients with cystic fibrosis, clinicians should keep in mind the diagnosis of ABPA for those CF patients that do not respond to usual medical therapy and have positive skin tests to Aspergillus allergens.
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Affiliation(s)
- Soheila Alyasin
- MD, Allergy Research Center, Department of Pediatrics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mozhgan Moghtaderi
- MD, Allergy Research Center, Allergy Clinic of Ali-asghar Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shirin Farjadian
- Ph.D., Professor in Immunology, Allergy Research Center, Department of Immunology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Babaei
- M.Sc. in Microbiology, Allergy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saeed Hosseini Teshnizi
- Ph.D. Candidate in Biostatistics, Clinical Research Development Center of Children Hospital, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
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Organization of Patient Management and Fungal Epidemiology in Cystic Fibrosis. Mycopathologia 2017; 183:7-19. [PMID: 29098487 PMCID: PMC7089279 DOI: 10.1007/s11046-017-0205-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/26/2017] [Indexed: 12/26/2022]
Abstract
The achievement of a better life for cystic fibrosis (CF) patients is mainly caused by a better management and infection control over the last three decades. Herein, we want to summarize the cornerstones for an effective management of CF patients and to give an overview of the knowledge about the fungal epidemiology in this clinical context in Europe. Data from a retrospective analysis encompassing 66,616 samples from 3235 CF patients followed-up in 9 CF centers from different European countries are shown.
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Aspergillus Bronchitis in Patients with Cystic Fibrosis. Mycopathologia 2017; 183:61-69. [PMID: 28819878 DOI: 10.1007/s11046-017-0190-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 08/06/2017] [Indexed: 10/19/2022]
Abstract
Aspergillus fumigatus frequently colonizes the airways of patients with cystic fibrosis (CF) and may cause various severe infections, such as bronchitis. Serological data, sputum dependent markers and longitudinal data of treated cases of Aspergillus bronchitis were evaluated for further description of this infection. This study, which comprises three substudies, aimed to analyze epidemiological data of Aspergillus in CF and the entity of Aspergillus bronchitis. In a first step, data of the German Cystic Fibrosis Registry were used to evaluate the frequency of Aspergillus colonization in patients with CF (n = 2599). Then a retrospective analysis of 10 cases of Aspergillus bronchitis was performed to evaluate longitudinal data for lung function and clinical presentation parameters: sputum production, cough and physical capacity. Finally, a prospective cohort study (n = 22) was conducted to investigate serological markers for Aspergillus bronchitis: total serum IgE, specific serum IgE, specific serum IgG, as well as sputum galactomannan, real-time PCR detection of Aspergillus DNA in sputum and fungal cultures. Analysis of the German CF registry revealed an Aspergillus colonization rate of 32.5% among the 2599 patients. A retrospective data analysis of 10 treated cases revealed the clinical course of Aspergillus bronchitis, including repeated positive sputum culture findings for A. fumigatus, no antibiotic treatment response, total serum IgE levels <200 kU/l, no observation of new pulmonary infiltrates and appropriate antifungal treatment response. Antifungal treatment durations of 4 ± 1.6 (2-6) weeks significantly reduced cough (P = 0.0067), sputum production (P < 0.0001) and lung function measures (P = 0.0358) but not physical capacity (P = 0.0794). From this retrospective study, a prevalence of 1.6% was calculated. In addition, two cases of Aspergillus bronchitis were identified in the prospective cohort study according to immunological, molecular and microbiological parameters. A prevalence of 9% was assessed. Aspergillus bronchitis appears to occur in a minority of colonized CF patients. Antifungal treatment may reduce respiratory symptoms and restore lung function.
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Shah A, Kunal S. A review of 42 asthmatic children with allergic bronchopulmonary aspergillosis. Asia Pac Allergy 2017; 7:148-155. [PMID: 28765819 PMCID: PMC5537079 DOI: 10.5415/apallergy.2017.7.3.148] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/05/2017] [Indexed: 12/28/2022] Open
Abstract
Background Allergic bronchopulmonary aspergillosis (ABPA) in children with asthma, not associated with cystic fibrosis, is yet to receive the recognition it deserves. Objective To highlight the presentation of ABPA in children with asthma. Methods This retrospective review documents the occurrence of pediatric ABPA over a period of 31 years in one unit. Children with asthma, eosinophilia and infiltrates on chest radiograph were screened for ABPA. In these patients, demonstration of immediate hypersensitivity response against Aspergillus species along with serological profile and pulmonary function testing were done. Bronchography/computed tomography (CT) of the chest demonstrated central bronchiectasis (CB). CT of the paranasal sinuses was done in patients with upper airways symptoms. In those suspected with allergic Aspergillus sinusitis (AAS) consent was sought from the parents for the invasive procedure needed for the diagnosis of AAS. Results Of the 349 patients with ABPA diagnosed, 42 (12.03%) were in the pediatric age group. The mean age on presentation was 12.9 ± 4 years with a male preponderance. All patients had asthma and positive intradermal/skin prick test against Aspergillus species. Ring shadows, the most common radiological presentation, were seen in 28 of 42 patients. Bronchography/CT of the chest demonstrated CB, a feature pathognomic of ABPA, in 32 of 42 patients. High attenuation mucus plugs was observed in 7 of 36 patients while ABPA-seropositive was diagnosed in 10 of 42 patients. On imaging, sinusitis was seen in 20 of 30 patients with upper airways symptoms of whom eight had suspected AAS. Three parents consented for surgery, which confirmed the diagnosis. Conclusion This study highlights the need to evaluate asthmatic children for ABPA as also to exclude AAS.
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Affiliation(s)
- Ashok Shah
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 110 007, India
| | - Shekhar Kunal
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 110 007, India
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Gupta K, Gupta P, Mathew JL, Bansal A, Singh G, Singh M, Chakrabarti A. Fatal Disseminated Aspergillus penicillioides Infection in a 3-Month-Old Infant with Suspected Cystic Fibrosis: Autopsy Case Report with Review of Literature. Pediatr Dev Pathol 2017; 19:506-511. [PMID: 26579953 DOI: 10.2350/15-10-1729-cr.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with cystic fibrosis (CF) often are colonized by Aspergillus species in their respiratory tract, but invasive aspergillosis is a rare complication. We describe the autopsy findings of an infant with cystic fibrosis who had fatal disseminated aspergillosis. The causative agent was identified as A. penicillioides by molecular technique. To our knowledge, this is the first report of disseminated aspergillosis caused by A. penicillioides in any type of patient. The literature on invasive aspergillosis in patients with cystic fibrosis also is reviewed.
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Affiliation(s)
- Kirti Gupta
- 1 Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Parikshaa Gupta
- 1 Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Joseph L Mathew
- 2 Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Bansal
- 2 Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Gangandeep Singh
- 3 Department of Medical Mycology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Meenu Singh
- 2 Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- 3 Department of Medical Mycology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Somayaji R, Ramos KJ, Kapnadak SG, Aitken ML, Goss CH. Common clinical features of CF (respiratory disease and exocrine pancreatic insufficiency). Presse Med 2017; 46:e109-e124. [PMID: 28554722 DOI: 10.1016/j.lpm.2017.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/06/2017] [Accepted: 03/29/2017] [Indexed: 12/17/2022] Open
Abstract
First described as a disease of the pancreas, cystic fibrosis is a genetically inherited progressive disease affecting multiple organ systems. Pulmonary and pancreatic involvement is common in individuals with cystic fibrosis, and the former is attributable to most of the mortality that occurs with the condition. This chapter provides an overview of a clinical approach to the pulmonary and pancreatic manifestations of cystic fibrosis.
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Affiliation(s)
- Ranjani Somayaji
- University of Calgary, Department of Medicine, Calgary, AB, Canada
| | - Kathleen J Ramos
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Siddhartha G Kapnadak
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Moira L Aitken
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Christopher H Goss
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA; University of Washington, Department of Pediatrics, Division of Pediatric Pulmonology, Seattle, WA, USA; Seattle Children's Research Institute, Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle, WA, USA.
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28
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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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Agarwal R, Sehgal IS, Dhooria S, Aggarwal AN. Developments in the diagnosis and treatment of allergic bronchopulmonary aspergillosis. Expert Rev Respir Med 2016; 10:1317-1334. [PMID: 27744712 DOI: 10.1080/17476348.2016.1249853] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder characterized by recurrent episodes of wheezing, fleeting pulmonary opacities and bronchiectasis. It is the most prevalent of the Aspergillus disorders with an estimated five million cases worldwide. Despite six decades of research, the pathogenesis, diagnosis and treatment of this condition remains controversial. The International Society for Human and Animal Mycology has formed a working group to resolve the controversies around this entity. In the year 2013, this group had proposed new criteria for diagnosis and staging, and suggested a treatment protocol for the management of this disorder. Since then, several pieces of new evidence have been published in the investigation and therapeutics of this condition. Areas covered: A non-systematic review of the available literature was performed. We summarize the current evidence in the evaluation and treatment of this enigmatic disorder. We suggest modifications to the existing criteria and propose a new scoring system for the diagnosis of ABPA. Expert commentary: All patients with asthma and cystic fibrosis should routinely be screened for ABPA using A. fumigatus-specific IgE levels. Glucocorticoids should be used as the first-line of therapy in ABPA, and itraconazole reserved in those with recurrent exacerbations and glucocorticoid-dependent disease.
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Affiliation(s)
- Ritesh Agarwal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Inderpaul S Sehgal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Sahajal Dhooria
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Ashutosh N Aggarwal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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Li JX, Fan LC, Li MH, Cao WJ, Xu JF. Beneficial effects of Omalizumab therapy in allergic bronchopulmonary aspergillosis: A synthesis review of published literature. Respir Med 2016; 122:33-42. [PMID: 27993289 DOI: 10.1016/j.rmed.2016.11.019] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/20/2016] [Accepted: 11/22/2016] [Indexed: 02/08/2023]
Abstract
Omalizumab, a humanized mAb that binds to IgE, has been an effective therapy for patients with severe allergic asthma; however, there are few clinical trials examining the efficacy of Omalizumab in patients with allergic bronchopulmonary aspergillosis (ABPA) except some case reports. To assess the clinical and immunological effects of Omalizumab in ABPA patients, we made a synthesis review of 102 cases from 30 published literature, analyzed the effects of Omalizumab therapy in ABPA and conducted subgroup analyses to determine factors that influenced the therapy endpoints. We found that Omalizumab treatment not only provided a clinically important reduction in serum IgE, exacerbation rates and steroid requirement, but also showed attenuated asthma symptoms and improved pulmonary function parameters in patients with ABPA. Moreover, further discussion was made when interpretating the results. Double-blind, randomized, placebo-controlled trials are necessary to establish the efficacy and safety of this novel therapeutic intervention for ABPA patients.
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Affiliation(s)
- Jian-Xiong Li
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Li-Chao Fan
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Man-Hui Li
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China; Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Soochow University, Suzhou, China
| | - Wei-Jun Cao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China; Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Soochow University, Suzhou, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China; Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Soochow University, Suzhou, China.
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31
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Elphick HE, Southern KW. Antifungal therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2016; 11:CD002204. [PMID: 27820955 PMCID: PMC6734115 DOI: 10.1002/14651858.cd002204.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is an allergic reaction to colonisation of the lungs with the fungus Aspergillus fumigatus and affects around 10% of people with cystic fibrosis. ABPA is associated with an accelerated decline in lung function. High doses of corticosteroids are the main treatment for ABPA; although the long-term benefits are not clear, their many side effects are well-documented. A group of compounds, the azoles, have activity against Aspergillus fumigatus and have been proposed as an alternative treatment for ABPA. Of this group, itraconazole is the most active. A separate antifungal compound, amphotericin B, has been employed in aerosolised form to treat invasive infection with Aspergillus fumigatus, and may have potential for the treatment of ABPA. Antifungal therapy for ABPA in cystic fibrosis needs to be evaluated. This is an update of a previously published review. OBJECTIVES The review aimed to test the hypotheses that antifungal interventions for the treatment of ABPA in cystic fibrosis:1. improve clinical status compared to placebo or standard therapy (no placebo);2. do not have unacceptable adverse effects.If benefit was demonstrated, we aimed to assess the optimal type, duration and dose of antifungal therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings.In addition, pharmaceutical companies were approached.Date of the most recent search of the Group's Trials Register: 29 September 2016. SELECTION CRITERIA Published or unpublished randomised controlled trials, where antifungal treatments have been compared to either placebo or no treatment, or where different doses of the same treatment have been used in the treatment of ABPA in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Four trials were identified by the searches; none of which was judged eligible for inclusion in the review. MAIN RESULTS No completed randomised controlled trials were included. AUTHORS' CONCLUSIONS At present, there are no randomised controlled trials to evaluate the use of antifungal therapies for the treatment of ABPA in people with cystic fibrosis, although trials in people who do not have cystic fibrosis have shown clinical and serological evidence of improvement and a reduction in the use of corticosteroids with no increase in adverse effects. Trials with clear outcome measures are needed to properly evaluate this potentially useful treatment for cystic fibrosis.
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Affiliation(s)
- Heather E Elphick
- Sheffield Children's HospitalRespiratory UnitWestern BankSheffieldUKS10 2TH
| | - Kevin W Southern
- University of LiverpoolDepartment of Women's and Children's HealthAlder Hey Children's NHS Foundation TrustEaton RoadLiverpoolMerseysideUKL12 2AP
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Maturu VN, Agarwal R. Prevalence of Aspergillus sensitization and allergic bronchopulmonary aspergillosis in cystic fibrosis: systematic review and meta-analysis. Clin Exp Allergy 2016; 45:1765-78. [PMID: 26177981 DOI: 10.1111/cea.12595] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/08/2015] [Accepted: 07/03/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prevalence of Aspergillus sensitization (AS) and allergic bronchopulmonary aspergillosis (ABPA) in cystic fibrosis (CF) has been varyingly reported. The aim of this systematic review was to estimate the overall prevalence of AS/ABPA in CF. METHODS We searched the PubMed and EmBase databases for studies reporting the prevalence of AS/ABPA in CF. We calculated the proportion with 95% confidence interval (CI) to assess the prevalence of AS and ABPA in the individual studies and then pooled the results using a random effects model. Statistical heterogeneity was assessed using the I2 test while publication bias was assessed using both graphical and statistical methods. RESULTS Our search yielded 64 eligible studies. The pooled prevalence of AS was 39.1% (95% CI: 33.3-45.1) and was higher with skin test compared to specific IgE (43.8% vs. 32.8%, P = 0.002); however, the prevalence did not vary with the type of skin test used (intradermal or percutaneous). The prevalence of ABPA was 8.9% (95% CI: 7.4-10.7) and was higher in adults as compared to children (10.1% vs. 8.9%, P < 0.0001). There was a wide variation in the criteria used for diagnosing ABPA. Almost 50% (12/23) of the publications after 2004 used criteria other than the CF foundation criteria for diagnosing ABPA. There was significant statistical heterogeneity and evidence of publication bias. CONCLUSIONS There is a high prevalence of AS and ABPA in patients with CF. Despite six decades of research, there is still a need to adopt uniform methodology and criteria for the diagnosis of AS/ABPA.
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Affiliation(s)
- V N Maturu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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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: 13] [Impact Index Per Article: 1.6] [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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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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Shah A, Panjabi C. Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2016; 8:282-97. [PMID: 27126721 PMCID: PMC4853505 DOI: 10.4168/aair.2016.8.4.282] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 05/15/2015] [Indexed: 01/30/2023]
Abstract
In susceptible individuals, inhalation of Aspergillus spores can affect the respiratory tract in many ways. These spores get trapped in the viscid sputum of asthmatic subjects which triggers a cascade of inflammatory reactions that can result in Aspergillus-induced asthma, allergic bronchopulmonary aspergillosis (ABPA), and allergic Aspergillus sinusitis (AAS). An immunologically mediated disease, ABPA, occurs predominantly in patients with asthma and cystic fibrosis (CF). A set of criteria, which is still evolving, is required for diagnosis. Imaging plays a compelling role in the diagnosis and monitoring of the disease. Demonstration of central bronchiectasis with normal tapering bronchi is still considered pathognomonic in patients without CF. Elevated serum IgE levels and Aspergillus-specific IgE and/or IgG are also vital for the diagnosis. Mucoid impaction occurring in the paranasal sinuses results in AAS, which also requires a set of diagnostic criteria. Demonstration of fungal elements in sinus material is the hallmark of AAS. In spite of similar histopathologic features, co-existence of ABPA and AAS is still uncommon. Oral corticosteroids continue to be the mainstay of management of allergic aspergillosis. Antifungal agents play an adjunctive role in ABPA as they help reduce the fungal load. Saprophytic colonization in cavitary ABPA may lead to aspergilloma formation, which could increase the severity of the disease. The presence of ABPA, AAS, and aspergilloma in the same patient has also been documented. All patients with Aspergillus-sensitized asthma must be screened for ABPA, and AAS should always be looked for.
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Affiliation(s)
- Ashok Shah
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India.
| | - Chandramani Panjabi
- Department of Respiratory Medicine, Mata Chanan Devi Hospital, New Delhi, India
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Giovannini-Chami L, Blanc S, Hadchouel A, Baruchel A, Boukari R, Dubus JC, Fayon M, Le Bourgeois M, Nathan N, Albertini M, Clément A, de Blic J. Eosinophilic pneumonias in children: A review of the epidemiology, diagnosis, and treatment. Pediatr Pulmonol 2016; 51:203-16. [PMID: 26716396 DOI: 10.1002/ppul.23368] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/24/2015] [Accepted: 12/02/2015] [Indexed: 12/19/2022]
Abstract
Pediatric eosinophilic pneumonias (EPs) are characterized by a significant infiltration of the alveolar spaces and lung interstitium by eosinophils, with conservation of the lung structure. In developed countries, EPs constitute exceptional entities in pediatric care. Clinical symptoms may be transient (Löffler syndrome), acute (<1 month and mostly <7 days), or chronic (>1 month). Diagnosis relies on demonstration of alveolar eosinophilia on bronchoalveolar lavage, whether or not associated with blood eosinophilia. EPs are a heterogeneous group of disorders divided into: (i) secondary forms (seen mainly in parasitic infections, allergic bronchopulmonary aspergillosis, and drug reactions); and (ii) primary forms (eosinophilic granulomatosis with polyangiitis, hypereosinophilic syndrome, idiopathic chronic eosinophilic pneumonia, and idiopathic acute eosinophilic pneumonia). Despite their rarity, the etiological approach to EP must be well-defined as some causes can be rapidly life-threatening without initiation of the proper treatment. This approach (i) eliminates secondary forms, with comprehensive history taking and minimal biological assessment, (ii) is oriented in primary forms by the acute or chronic setting, and the existence of extrapulmonary symptoms. Treatment of primary forms has traditionally relied on corticosteroids, usually with a dramatic response. Specific treatments or the adjunction of corticosteroid-sparing treatment or immunosuppressors are currently being evaluated in order to improve the prognosis and the side effects associated with corticosteroid treatment in a pediatric setting.
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Affiliation(s)
- Lisa Giovannini-Chami
- Department of Pediatric Pulmonology and Allergology, Hôpitaux pédiatriques de Nice CHU-Lenval, Nice, France.,Université de Nice Sophia Antipolis, Nice, France
| | - Sibylle Blanc
- Department of Pediatric Pulmonology and Allergology, Hôpitaux pédiatriques de Nice CHU-Lenval, Nice, France
| | - Alice Hadchouel
- Department of Pediatric Pulmonology, AP-HP, Hôpital Necker Enfants Malades, Paris, France.,Université Paris Descartes-Paris 5, Paris, France
| | - André Baruchel
- Department of Pediatric Hematology, AP-HP, Hôpital Robert Debré, Paris, France.,Université Paris Diderot VII, Paris, France
| | - Rachida Boukari
- Department of Pediatric Pulmonology, Centre Hospitalier Universitaire Mustapha, Alger, Algérie
| | - Jean-Christophe Dubus
- Department of Pediatric Pulmonology, Centre Hospitalier Universitaire de Marseille, Marseille, France
| | - Michael Fayon
- Department of Pediatric Pulmonology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Département de Pédiatrie, Centre d'Investigation Clinique, Bordeaux, France
| | - Muriel Le Bourgeois
- Department of Pediatric Pulmonology, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Nadia Nathan
- Department of Pediatric Pulmonology, AP-HP, Hôpital Trousseau, Paris, France.,Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Marc Albertini
- Department of Pediatric Pulmonology and Allergology, Hôpitaux pédiatriques de Nice CHU-Lenval, Nice, France.,Université de Nice Sophia Antipolis, Nice, France
| | - Annick Clément
- Department of Pediatric Pulmonology, AP-HP, Hôpital Trousseau, Paris, France.,Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jacques de Blic
- Department of Pediatric Pulmonology, AP-HP, Hôpital Necker Enfants Malades, Paris, France.,Université Paris Descartes-Paris 5, Paris, France
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Saunders RV, Modha DE, Claydon A, Gaillard EA. Chronic Aspergillus fumigatus colonization of the pediatric cystic fibrosis airway is common and may be associated with a more rapid decline in lung function. Med Mycol 2016; 54:537-43. [PMID: 26782645 DOI: 10.1093/mmy/myv119] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 12/18/2015] [Indexed: 11/12/2022] Open
Abstract
Filamentous fungi are commonly isolated from the respiratory tract of CF patients, but their clinical significance is uncertain and the reported incidence variable. We report on the degree of Aspergillus fumigatus airway colonization in a tertiary pediatric CF cohort, evaluate the sensitivity of routine clinical sampling at detecting A. fumigatus, and compare lung function of A. fumigatus-colonized and non-colonized children.We carried out an 8-year retrospective cohort analysis using local databases, examining 1024 respiratory microbiological specimens from 45 children. Nineteen (42%) had a positive A. fumigatus culture at least once during the 8-year period, with 10 (22%) children persistently colonized. Overall, 29% of 48 bronchoalveolar lavage (BAL) samples tested positive for A. fumigatus, compared with 14% of 976 sputum samples. Of 33 children for whom lung function data were available during the study period, seven were classed as having severe lung disease, of whom four (57%) were persistently colonized with A. fumigatus.We conclude that chronic A. fumigatus colonization of the CF airway is common, and may be associated with worse lung function. In our practice, BAL appears superior at detecting lower airway A. fumigatus compared to sputum samples.
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Affiliation(s)
- Rosalind V Saunders
- University Hospitals of Leicester NHS Trust, Department of Clinical Microbiology, Infirmary Square, Leicester, UK
| | - Deborah E Modha
- University Hospitals of Leicester NHS Trust, Department of Clinical Microbiology, Infirmary Square, Leicester, UK
| | - Alison Claydon
- Children's Hospital, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, UK
| | - Erol A Gaillard
- University of Leicester, Dept. of Infection, Immunity and Inflammation, University Road, Leicester, UK Children's Hospital, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, UK Institute for Lung Health, NIHR Leicester Respiratory Biomedical Research Unit, Leicester, UK
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Jat KR, Walia DK, Khairwa A. Anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2015:CD010288. [PMID: 26545165 DOI: 10.1002/14651858.cd010288.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive multisystem disorder with an approximate prevalence of 1 in 3500 live births. Allergic bronchopulmonary aspergillosis is a lung disease caused by aspergillus-induced hypersensitivity with a prevalence of 2% to 15% in people with cystic fibrosis. The mainstay of treatment includes corticosteroids and itraconazole. The treatment with corticosteroids for prolonged periods of time, or repeatedly for exacerbations of allergic bronchopulmonary aspergillosis, may lead to many adverse effects. The monoclonal anti-IgE antibody, omalizumab, has improved asthma control in severely allergic asthmatics. The drug is given as a subcutaneous injection every two to four weeks. Since allergic bronchopulmonary aspergillosis is also a condition resulting from hypersensitivity to specific allergens, as in asthma, it may be a candidate for therapy using anti-IgE antibodies. Therefore, anti-IgE therapy, using agents like omalizumab, may be a potential therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. This is an updated version of the review. OBJECTIVES To evaluate the efficacy and adverse effects of anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Last search: 27 July 2015.We searched the ongoing trial registry clinicaltrials.gov for any ongoing trials. Latest search for clinicaltrials.gov: 23 October 2015. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing anti-IgE therapy to placebo or other therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias in the included study. They planned to perform data analysis using Review Manager. MAIN RESULTS Only one study enrolling 14 participants was eligible for inclusion in the review. The double-blind study compared a daily dose of 600 mg omalizumab or placebo along with twice daily itraconazole and oral corticosteroids, with a maximum daily dose of 400 mg. Treatment lasted six months but the study was terminated prematurely and complete data were not available. We contacted the study investigator and were told that the study was terminated due to the inability to recruit participants into the study despite all reasonable attempts. One or more serious side effects were encountered in six out of nine (66.67%) and one out of five (20%) participants in omalizumab group and placebo group respectively. AUTHORS' CONCLUSIONS There is lack of evidence for the efficacy and safety of anti-IgE (omalizumab) therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis. There is a need for large prospective randomized controlled studies of anti-IgE therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis with both clinical and laboratory outcome measures such as steroid requirement, allergic bronchopulmonary aspergillosis exacerbations and lung function.
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Affiliation(s)
- Kana R Jat
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India, 110029
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Kopp BT, Nicholson L, Paul G, Tobias J, Ramanathan C, Hayes D. Geographic variations in cystic fibrosis: An analysis of the U.S. CF Foundation Registry. Pediatr Pulmonol 2015; 50:754-62. [PMID: 25825016 DOI: 10.1002/ppul.23185] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/29/2014] [Accepted: 01/23/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Emerging evidence suggests that the prevalence of pathogens common in cystic fibrosis (CF) may be unevenly distributed across the United States (U.S.). However, very little is known regarding the U.S. distribution of other CF modifiers such as medication usage and patient demographics. Therefore, we sought to determine if regional differences exist in the distribution of demographic variables and patient disease characteristics in the U.S. that may play a role in differential CF outcomes. METHODS Data were analyzed from the 30,896 subjects in the U.S. CF Foundation Patient Registry during the years 2007-2012, via geographical grouping of states based upon the Nationwide Inpatient Sample classification. RESULTS Significant differences in racial distribution were seen, including half of the total U.S. African-American CF population residing in the South. Both African-Americans and Hispanics had increased Medicaid usage (52.2%, 41.8%, respectively). Culture-reported pathogens were markedly different across the U.S., with the highest percentage of patients with Methicillin-resistant Staphylococcus aureus (41.9%), Pseudomonas aeruginosa (71.2%), and non-tuberculous mycobacterium (10.0%) in the South. The South region also had the lowest mean body mass index and forced expiratory volume in one second. Chronic medication usage such as inhaled tobramycin or macrolides followed P. aeruginosa distribution, while inhaled dornase alfa was most used in the West (84.7%). Co-morbid conditions varied, with the highest percentage of depressed subjects in the Midwest (18.3%). Mean regional mortality rates were not statistically different among regions, although highest in each age grouping of the South. CONCLUSIONS The U.S. has significant regional variations in CF demographics, insurance, pathogens, medication usage, and co-morbidities, without an overall impact on regional mortality. Regional variations in care practices should be studied further based on the findings.
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Affiliation(s)
- Benjamin T Kopp
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio.,Center for Microbial Pathogenesis, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Lisa Nicholson
- Institute for Population Research, The Ohio State University, Columbus, Ohio
| | - Grace Paul
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Chandar Ramanathan
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Don Hayes
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Singh M, Das S, Chauhan A, Paul N, Sodhi KS, Mathew J, Chakrabarti A. The diagnostic criteria for allergic bronchopulmonary aspergillosis in children with poorly controlled asthma need to be re-evaluated. Acta Paediatr 2015; 104:e206-9. [PMID: 25620428 DOI: 10.1111/apa.12930] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 01/13/2015] [Indexed: 01/20/2023]
Abstract
AIM The aim of this study was to examine the association between allergic bronchopulmonary aspergillosis (ABPA) and poorly controlled asthma in children and appraise the diagnostic criteria. METHODS The study included 100 children with poorly controlled asthma. We diagnosed ABPA using the Aspergillus skin test, pulmonary function test, total and specific immunoglobulin E (IgE) to Aspergillus fumigatus, chest radiograph and high-resolution computed tomography. Patients were diagnosed and classified according to the Rosenberg-Patterson criteria for ABPA. The cut-off value for total serum IgE was calculated by receiver operating characteristics curve analysis. RESULTS Of 100 children with poorly controlled asthma, 26 patients were ABPA positive. There was a significant difference in the forced expiratory volume in 1-sec/forced vital capacity ratio between ABPA positive (0.78 ± 0.14) and negative (0.87 ± 0.15) children (p = 0.008). ABPA positive children were categorised as seropositive, central bronchiectasis and other radiological findings. The receiver operating characteristics curve was constructed, and a value of 1200 IU/mL of total IgE was observed, with 88.5% sensitivity and 70.5% specificity. CONCLUSION This study showed an association between ABPA and poorly controlled asthma in children and suggests a higher cut-off value of total IgE for the diagnosis of ABPA.
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Affiliation(s)
- Meenu Singh
- Advanced Pediatric Centre; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Subhamoy Das
- Advanced Pediatric Centre; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Anil Chauhan
- Advanced Pediatric Centre; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Nandini Paul
- Advanced Pediatric Centre; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Kushaljit Singh Sodhi
- Department of Radiodiagnosis; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Joseph Mathew
- Advanced Pediatric Centre; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology; Post Graduate Institute of Medical Education and Research; Chandigarh India
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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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Cottin V, Cordier JF. Eosinophilic Pneumonia. ORPHAN LUNG DISEASES 2015. [PMCID: PMC7121898 DOI: 10.1007/978-1-4471-2401-6_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Eosinophilic pneumonia may manifest as chronic or transient infiltrates with mild symptoms, chronic idiopathic eosinophilic pneumonia, or the frequently severe acute eosinophilic pneumonia that may be secondary to a variety of causes (drug intake, new onset of tobacco smoking, infection) and that may necessitate mechanical ventilation. When present, blood eosinophilia greater than 1 × 109 eosinophils/L (and preferably greater than 1.5 × 109/L) is of considerable help for suggesting the diagnosis, however it may be absent, as in the early phase of idiopathic acute eosinophilic pneumonia or when patients are already taking corticosteroids. On bronchoalveolar lavage, high eosinophilia (>25 %, and preferably >40 % of differential cell count) is considered diagnostic of eosinophilic pneumonia in a compatible setting, obviating the need of video-assisted thoracic surgical lung biopsy, which is now performed only on very rare occasions with inconsistency between clinical, biological, and imaging features. Inquiry as to drug intake must be meticulous (www.pneumotox.com) and any suspected drug should be withdrawn. Laboratory investigations for parasitic causes must take into account the travel history or residence and the epidemiology of parasites. In patients with associated extrathoracic manifestations, the diagnosis of eosinophilic granulomatosis with polyangiitis or of the hypereosinophilic syndromes should be raised. Presence of airflow obstruction can be found in hypereosinophilic asthma, allergic bronchopulmonary aspergillosis, idiopathic chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis, or in the recently identified syndrome of hyperosinophilic obliterative bronchiolitis. Corticosteroids remain the cornerstone of symptomatic treatment for eosinophilic pneumonias, with a generally dramatic response. Relapses are common when tapering the doses or after stopping treatment especially in idiopathic chronic eosinophilic pneumonia. Cyclophosphamide is necessary only in patients with eosinophilic granulomatosis with polyangiitis and poor-prognostic factors. Imatinib is very effective in the treatment of the myeloproliferative variant of hypereosinophilic syndromes. Anti-interleukin-5 monoclonal antibodies are promising in the spectrum of eosinophilic disorders.
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Elphick HE, Southern KW. Antifungal therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2014:CD002204. [PMID: 25431975 DOI: 10.1002/14651858.cd002204.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is an allergic reaction to colonisation of the lungs with the fungus Aspergillus fumigatus and affects around 10% of people with cystic fibrosis. ABPA is associated with an accelerated decline in lung function. High doses of corticosteroids are the main treatment for ABPA; although the long-term benefits are not clear, their many side effects are well-documented. A group of compounds, the azoles, have activity against Aspergillus fumigatus and have been proposed as an alternative treatment for ABPA. Of this group, itraconazole is the most active. A separate antifungal compound, amphotericin B, has been employed in aerosolised form to treat invasive infection with Aspergillus fumigatus, and may have potential for the treatment of ABPA. Antifungal therapy for ABPA in cystic fibrosis needs to be evaluated. OBJECTIVES The review aimed to test the hypotheses that antifungal interventions for the treatment of ABPA in cystic fibrosis:1. improve clinical status compared to placebo or standard therapy (no placebo);2. do not have unacceptable adverse effects.If benefit was demonstrated, we aimed to assess the optimal type, duration and dose of antifungal therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings.In addition, pharmaceutical companies were approached.Date of the most recent search of the Group's Trials Register: 17 March 2014. SELECTION CRITERIA Published or unpublished randomised controlled trials, where antifungal treatments have been compared to either placebo or no treatment, or where different doses of the same treatment have been used in the treatment of ABPA in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Four trials were identified by the searches; none of which was judged eligible for inclusion in the review. MAIN RESULTS No completed randomised controlled trials were included. AUTHORS' CONCLUSIONS At present, there are no randomised controlled trials to evaluate the use of antifungal therapies for the treatment of ABPA in people with cystic fibrosis, although trials in people who do not have cystic fibrosis have shown clinical and serological evidence of improvement and a reduction in the use of corticosteroids with no increase in adverse effects. Trials with clear outcome measures are needed to properly evaluate this potentially useful treatment for cystic fibrosis.
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Affiliation(s)
- Heather E Elphick
- Respiratory Unit, Sheffield Children's Hospital, Western Bank, Sheffield, UK, S10 2TH
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Warris A. The biology of pulmonary aspergillus infections. J Infect 2014; 69 Suppl 1:S36-41. [PMID: 25135079 DOI: 10.1016/j.jinf.2014.07.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2014] [Indexed: 01/08/2023]
Abstract
Pulmonary aspergillus infections are mainly caused by Aspergillus fumigatus and can be classified based on clinical syndromes into saphrophytic infections, allergic disease and invasive disease. Invasive pulmonary aspergillosis, occurring in immunocompromised patients, reflects the most serious disease with a high case-fatality rate. Patients with cystic fibrosis and severe asthma might develop allergic bronchopulmonary aspergillosis, while saphrophytic infections are observed in patients with lung cavities mainly due to tuberculosis. Histopathologically, a differentiation can be made into angio-invasive and airway-invasive disease. If the host response is too weak or too strong, Aspergillus species are able to cause disease characterized either by damage from the fungus itself or through an exaggerated inflammatory response of the host, in both situations leading to overt disease associated with specific clinical signs and symptoms. The unraveling of the specific host - Aspergillus interaction has not been performed to a great extent and needs attention to improve the management of those clinical syndromes.
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Affiliation(s)
- Adilia Warris
- University of Aberdeen, School of Medicine and Dentistry, Division of Applied Medicine, Institute of Medical Sciences, Foresterhill, Aberdeen AB25 2ZD, Scotland, UK.
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Armstead J, Morris J, Denning DW. Multi-country estimate of different manifestations of aspergillosis in cystic fibrosis. PLoS One 2014; 9:e98502. [PMID: 24914809 PMCID: PMC4051580 DOI: 10.1371/journal.pone.0098502] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 05/03/2014] [Indexed: 01/01/2023] Open
Abstract
Aspergillus spp. can lead to allergic bronchopulmonary aspergillosis (ABPA), Aspergillus sensitisation and Aspergillus bronchitis in CF. The relative frequencies of these entities have recently been ascertained in a large UK adult CF cohort. We have used this data to estimate the burden of aspergillosis and ABPA cases in adult CF patients in 30 countries reporting CF. National and international CF registry data was accessed and assessed for completeness and age distribution. Published proportions of ABPA (17.7%), Aspergillus sensitisation (14.6%) and Aspergillus bronchitis (30%) in CF were applied to those >18 years and compared with notified ABPA cases. Of the 76,201 estimated CF patients worldwide (not including India), 37,714 were >18 years. The proportion of adults to children varied from 63% in Norway to 20% in Brazil. ABPA caseload in adults is anticipated to be 6,675 cases of which only 2,221 cases (33%) are currently recorded, indicating substantial underdiagnosis. The ABPA diagnosis rate compared with estimated rates varies by country from 101% (France) to 14.5% (Greece), although genetic variation could account for genuine differences compared with the UK. Aspergillus bronchitis is not currently recognised or recorded in CF registries but there are an anticipated 10,988 adult cases. Aspergillus sensitisation, associated with increased bronchiectasis and reduced FEV1, affects an anticipated 5,506 patients without ABPA or Aspergillus bronchitis. Together ABPA and Aspergillus bronchitis are estimated to affect 17,989 adults, 47.7% of the adult CF population. ABPA also occurs in children and teenagers and 984 cases were documented in registries. Diagnosed ABPA rates by age were available for the ECFS registry, USA, UK, Ireland, Belgium and Netherlands. The rate was <1% under 4 years, and increased throughout childhood and adolescence, with marked variation between countries. Newly published diagnostic criteria and methods should facilitate better recognition of aspergillosis in CF, allowing better CF disease control.
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Affiliation(s)
- Joanne Armstead
- National Aspergillosis Centre, University Hospital South Manchester, The University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Julie Morris
- National Aspergillosis Centre, University Hospital South Manchester, The University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - David W. Denning
- National Aspergillosis Centre, University Hospital South Manchester, The University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom
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46
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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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Livnat G, Bar-Yoseph R, Mory A, Dagan E, Elias N, Gershoni R, Bentur L. Duplication in CHIT1 gene and the risk for Aspergillus lung disease in CF patients. Pediatr Pulmonol 2014; 49:21-7. [PMID: 23359515 DOI: 10.1002/ppul.22749] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 12/28/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND Aspergillus often persists in the respiratory tract of patients with Cystic Fibrosis (CF) and may cause allergic broncho-pulmonary aspergillosis (ABPA). Chitinases are enzymes that digest the chitin polymer. Plants use chitinase as a defense mechanism against fungi. Chitotriosidase (CHIT1) is the major chitinase in human airways. Variation in the coding region with 24-bp duplication allele results in reduced CHIT1 activity. Recently, CHIT1 duplication heterozygocity was found in 6/6 patients with severe asthma and fungal sensitization (SAFS). AIM Our aim was to evaluate the link between CHIT1 duplication in CF patients and the predisposition to Allergic broncho-pulmonary mycosis (ABPM) or persistent Aspergillus positive sputum (APS). PATIENTS AND METHODS CHIT1 duplication was assessed in three CF groups. Group 1: patients who had neither ABPM nor APS in the past (control group). Group 2: patients with persistent APS (≥2/year), without ABPA. Group 3: patients with current or past ABPM. RESULTS Forty patients with CF were included in the analysis, CHIT1 duplication heterozygocity was found in 3/6 (50%) of the patients in the ABPM group, 3/12 (25%) in the APS group, and 7/22 (31.8%) in the control group (P > 0.05). Eleven patients carried W1282X mutation, 90.9% were negative for CHIT1 duplication, five of them were homozygous for W1282X; none of them had CHIT1 duplication or ABPM. CONCLUSIONS CHIT1 duplication is not found in all CF patients with ABPM in contrast to patients with SAFS. These results suggest that CHIT1 duplication cannot be the sole explanation for Aspergillus positive sputum in CF patients.
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Affiliation(s)
- Galit Livnat
- Pediatric Pulmonary Unit, Meyer Children's Hospital, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Ng MY, Flight W, Smith E. Pulmonary complications of cystic fibrosis. Clin Radiol 2013; 69:e153-62. [PMID: 24361142 DOI: 10.1016/j.crad.2013.10.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 10/29/2013] [Accepted: 10/30/2013] [Indexed: 01/15/2023]
Abstract
The life expectancy of patients with cystic fibrosis (CF) has steadily increased over recent decades with a corresponding increase in the frequency of complications of the disease. Radiologists are increasingly involved with managing and identifying the pulmonary complications of CF. This article reviews the common manifestations of CF lung disease as well as updating radiologists with a number of less well-known complications of the condition. Early and accurate detection of the pulmonary effects of CF are increasingly important to prevent irreversible lung damage and give patients the greatest possibility of benefiting from the new therapies becoming available, which correct the underlying defect causing CF.
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Affiliation(s)
- M Y Ng
- Department of Radiology, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK.
| | - W Flight
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, UK
| | - E Smith
- Department of Radiology, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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49
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Jat KR, Walia DK, Khairwa A. Anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2013:CD010288. [PMID: 24043500 DOI: 10.1002/14651858.cd010288.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive multisystem disorder with an approximate prevalence of 1 in 3500 live births. Allergic bronchopulmonary aspergillosis is a lung disease caused by aspergillus-induced hypersensitivity with a prevalence of 2% to 15% in people with cystic fibrosis. The mainstay of treatment includes corticosteroids and itraconazole. The treatment with corticosteroids for prolonged periods of time, or repeatedly for exacerbations of allergic bronchopulmonary aspergillosis, may lead to many adverse effects. The monoclonal anti-IgE antibody, omalizumab, has improved asthma control in severely allergic asthmatics. The drug is given as a subcutaneous injection every two to four weeks. Since allergic bronchopulmonary aspergillosis is also a condition resulting from hypersensitivity to specific allergens, as in asthma, it may be a candidate for therapy using anti-IgE antibodies. Therefore, anti-IgE therapy, using agents like omalizumab, may be a potential therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. OBJECTIVES To evaluate the efficacy and adverse effects of anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Last search: 21 January 2013.We searched the ongoing trial registry clinicaltrials.gov for any ongoing trials. Latest search for clinicaltrials.gov: 22 February 2013. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing anti-IgE therapy to placebo or other therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias in the included study. They planned to perform data analysis using Review Manager 5.1. MAIN RESULTS Only one trial enrolling 14 patients was eligible for inclusion in the review. The study was terminated prematurely and complete data were not available. We contacted the study investigator and were told that the study was terminated due to the inability to recruit patients into the study despite all reasonable attempts. One or more serious side effects were encountered in six out of nine (66.67%) and one out of five (20%) patients in omalizumab group and placebo group respectively. AUTHORS' CONCLUSIONS There is lack of evidence for the efficacy and safety of anti-IgE (omalizumab) therapy in patients with cystic fibrosis and allergic bronchopulmonary aspergillosis. There is a need for large prospective randomized controlled trials of anti-IgE therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis with both clinical and laboratory outcome measures such as steroid requirement, allergic bronchopulmonary aspergillosis exacerbations and lung function.
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Affiliation(s)
- Kana R Jat
- Department of Pediatrics, Government Medical College and Hospital, Sector-32, Chandigarh, Chandigarh UT, India, 160030
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Baxter CG, Dunn G, Jones AM, Webb K, Gore R, Richardson MD, Denning DW. Novel immunologic classification of aspergillosis in adult cystic fibrosis. J Allergy Clin Immunol 2013; 132:560-566.e10. [PMID: 23726262 DOI: 10.1016/j.jaci.2013.04.007] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 03/10/2013] [Accepted: 04/01/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Patients with cystic fibrosis (CF) demonstrate a wide range of hypersensitivity responses to Aspergillus, beyond allergic bronchopulmonary aspergillosis, which require classification. OBJECTIVE This study integrated 2 new methods of Aspergillus detection-sputum galactomannan (GM) and real-time PCR-alongside established serologic markers, to reclassify aspergillosis in CF. METHODS A total of 146 adult patients with CF had serologic tests (ImmunoCap total IgE, specific Aspergillus fumigatus IgE, and specific A fumigatus IgG), sputum real-time Aspergillus PCR, and sputum GM. Patients were classified by using latent class analysis. RESULTS Both RT-PCR and GM were more sensitive than culture in detecting Aspergillus in sputum (culture 37%, RT-PCR 74%, and GM 46%). Intraassay and interassay reproducibility of PCR and GM was excellent. Latent class analysis of triazole-naive patients identified a nondiseased group and 3 disease classes: class 1 (n = 49, 37.7%) represented patients with or without positive RT-PCR but no immunologic response to A fumigatus and negative GM (nondiseased); class 2 (n = 23, 17.7%) represented patients with positive RT-PCR, elevated total and specific A fumigatus IgE/IgG, and positive GM (serologic allergic bronchopulmonary aspergillosis); class 3 (n = 19, 14.6%) represented patients with or without positive RT-PCR, elevated A fumigatus IgE (not IgG), and negative GM (Aspergillus sensitized); and class 4 (n = 39, 30%) represented patients with positive RT-PCR, elevated A fumigatus IgG (not IgE), and positive GM (Aspergillus bronchitis). CONCLUSIONS Three distinct classes of aspergillosis in CF were identified by latent class analysis by using serologic, RT-PCR, and GM data. This novel classification will facilitate improved phenotyping, pathogenesis studies, and management evaluations.
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Affiliation(s)
- Caroline G Baxter
- National Aspergillosis Centre, University Hospital of South Manchester, Manchester, United Kingdom; Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester, Manchester, United Kingdom; The University of Manchester and the Manchester Academic Health Science Centre, Manchester, United Kingdom.
| | - Graham Dunn
- Health Sciences Methodology, School of Community Based Medicine, University of Manchester, Manchester, United Kingdom
| | - Andrew M Jones
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester, Manchester, United Kingdom; The University of Manchester and the Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Kevin Webb
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester, Manchester, United Kingdom; The University of Manchester and the Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Robin Gore
- The University of Manchester and the Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Malcolm D Richardson
- National Aspergillosis Centre, University Hospital of South Manchester, Manchester, United Kingdom; The University of Manchester and the Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - David W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, Manchester, United Kingdom; The University of Manchester and the Manchester Academic Health Science Centre, Manchester, United Kingdom
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