Allergic bronchopulmonary aspergillosis in three patients with normal chest x-ray films

Severe asthma with fungal sensitization: a case report and review of literature

There is a substantial body of evidence supporting an association between asthma severity and fungal exposure and sensitization. Fungal allergens are a recognized risk factor for severe asthma. We describe the case of a 44-year-old asthmatic whose asthma control deteriorated after moving to a new flat with walls covered in mould. Allergic bronchopulmonary aspergillosis was excluded. Although sensitization to Candida was demonstrated by a positive Candida-specific radioallergosorbent test, the patient did not entirely satisfy the criteria for a diagnosis of allergic bronchopulmonary candidiasis. The patient's asthma control improved after engaging in a monthly washing regimen of the walls. This case further demonstrates the association between fungal sensitization and asthma severity. The term severe asthma with fungal sensitization has been recently coined to describe this phenomenon.

Diagnosis and treatment of allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is an underdiagnosed pulmonary disorder in asthmatic patients and patients with cystic fibrosis. Its clinical and diagnostic manifestations arise from an allergic response to multiple antigens expressed by fungi, most commonly Aspergillus fumigatus, colonizing the bronchial mucus. The clinical course is one of recurrent exacerbations characterized by chest infiltrates evident on chest x-ray films and associated with cough, wheeze, and sputum production that usually respond to oral corticosteroid treatment. Specific immunologic and radiologic markers of disease include elevation of the total serum IgE levels, presence of aspergillus IgE antibodies, and the occurrence of central bronchiectasis. Long-term treatment with corticosteroids is often required for effective management. The adverse effects of chronic corticosteroid use have led to attempts at treatment with antifungal agents such as itraconazole. Itraconazole has been reported anecdotally to be effective, and evidence for its effectiveness in randomized trials is still accruing. Consideration should be given to its use as a corticosteroid-sparing agent or for treatment of patients in whom corticosteroid response is poor. The natural history and prognosis of ABPA are not well characterized but may be complicated by progression to bronchiectasis and pulmonary fibrosis. If ABPA is diagnosed and treated before the development of bronchiectasis and fibrosis, these complications may be prevented.

Rise in total IgE as an indicator of allergic bronchopulmonary aspergillosis in cystic fibrosis

BACKGROUND

Allergic bronchopulmonary aspergillosis is a serious complication of cystic fibrosis and may be difficult to diagnose. The aim of this study was to define the usefulness of measuring total IgE compared with other major criteria in the diagnosis of allergic bronchopulmonary aspergillosis in children with cystic fibrosis.

METHODS

A retrospective analysis was carried out of the case records of 160 children attending a tertiary referral paediatric cystic fibrosis clinic.

RESULTS

Sixteen children had a total IgE level above 500 IU/ml. Eleven children had six or more other major criteria and were considered to have allergic bronchopulmonary aspergillosis. These 11 children had a fourfold rise in IgE in association with clinical deterioration. A further child had a fourfold rise in IgE to 341 IU/l, and was also thought to have allergic bronchopulmonary aspergillosis. Eleven had a fall in IgE with successful treatment; one patient died with uncontrolled disease. Only one of these 12 children had negative precipitins to Aspergillus fumigatus. The five children with a raised IgE not thought to have bronchopulmonary aspergillosis had four or fewer major criteria and were not treated; none had positive precipitins.

CONCLUSIONS

A fourfold rise in total IgE, particularly to above 500 IU/ml, is strongly suggestive of the diagnosis of allergic bronchopulmonary aspergillosis in children with cystic fibrosis. The measurement of total IgE has the merit of being simple to perform and objective. Positive aspergillus precipitins provide useful confirmatory evidence. These two criteria, taken in conjunction with clinical deterioration and new radiological shadowing, allow simplification of the diagnosis of allergic bronchopulmonary aspergillosis in cystic fibrosis.

Cystic fibrosis and allergic bronchopulmonary aspergillosis

We have prospectively screened our patients with cystic fibrosis for allergic bronchopulmonary aspergillosis. Over a three year period eight patients were identified, an incidence of 5.8%. Patients were clinically well at the time of diagnosis (Shwachman scores 70-90, Chrispin-Norman chest x ray scores 2-15) and they responded rapidly to treatment with oral prednisolone. There has been little deterioration in their respiratory function and nutrition over the study period. We conclude that allergic bronchopulmonary aspergillosis is not uncommon in patients with cystic fibrosis. It is a potential cause of lung damage and prospective screening could lead to earlier detection and treatment.

Pathogenetic and serological aspects of pulmonary aspergillosis

Af is an important pathogen of the bronchopulmonary system, and the clinical spectrum encompasses aspergilloma, CNPA, IPA, ABPA, bronchial asthma, and allergic alveolitis. Bronchial carriage may, however, not always be associated with pathological effects. The polymorphism of the aspergillus-related disorders seems mostly to depend upon the different responses of the hosts. This review considers the antigenic composition of Af and specific antibody responses in man in relation to the pathogenesis and diagnosis of the various forms of pulmonary aspergillosis. More than 200 macromolecular components have been listed for Af and more than 30 antigens found to react with human sera. Serum antibodies to Af are common in healthy subjects. Schønheyder and his associates (A-L) have shown that IgG, IgA and IgM antibodies in healthy subjects are directed towards antigens to which also patients with aspergillosis strongly react. With immunofluorescent staining these antigens were found to be associated with hyphal walls, and a MW 470,000 fraction from ruptured mycelium was most reactive in ELISA. The respiratory tract appears to be the major route for exposure since the humoral responses include IgA class antibodies, and sIgA antibodies are found in bronchial secretions. Moreover, IgG antibody levels to the MW 470,000 fraction correlate with occupational exposure and smoking habits. In patients with cystic fibrosis high IgG antibody levels to MW 470,000 and MW 25,000-50,000 antigen fractions were associated with the carriage of Af in the sputum. An individual patient's level of IgA antibodies to the MW 470,000 fraction was inversely related to the Af carrier rate, and this was also true for IgE dependent reactivity to Af antigens. These observations indicate that IgG antibodies to some antigens mirror the extent of antigenic exposure, whereas some IgA and IgE antibodies may play a protective role against bronchial colonization with Af. IgG antibody determinations by ELISA were found to provide a higher diagnostic efficacy in pulmonary aspergillosis than IgA antibody assays. With IgG antibodies there were statistically significant differences between patients and the controls and there was little overlap of ELISA values between the groups. The fractions of MW 250,000 with catalase activity and MW 25,000-50,000 with protease activity, were most suitable for serological diagnosis. A gel immunoelectrophoretic assay proved Af catalase to be a major diagnostic antigen in patients with aspergilloma or with an apical aspergillus lung infiltrate.(ABSTRACT TRUNCATED AT 400 WORDS)

Aspergillosis--clinical aspects

Allergic bronchopulmonary aspergillosis (ABPA) is much more common than originally suspected, can have its onset in childhood and remain undiagnosed for years or decades, at which time it presents in a patient with end-stage fibrotic lung disease. In other patients, ABPA may cause a finite number of roentgenographic lesions and not be associated with chronic sputum production or widespread bronchiectasis. Clinical symptoms range from the patient being asymptomatic with a new roentgenographic infiltrate being suspected only by a sharp elevation of total serum IgE to wheezing dyspnea or status asthmaticus. Serologic assays that are of major value in diagnosis of ABPA include elevation of total serum IgE--not all of which is directed against Aspergillus fumigatus, precipitating antibodies to A. fumigatus--unless the patient is in remission, and elevated serum IgE-A. fumigatus and IgG-A. fumigatus compared to serum from patients with asthma with immediate cutaneous reactivity to A. fumigatus but without evidence of ABPA. Five stages have been identified which reflect the time of recognition of ABPA and disease activity. They are Acute, Remission, Recurrent Exacerbation, Corticosteroid-Dependent Asthma, and Fibrotic. Stage I (Acute) patients have the classic clinical, serologic, and radiologic features of ABPA. Stage II (Remission) occurs after prednisone has resulted in resolution of the chest infiltrate and can be tapered and discontinued for 6 months without new infiltrates. Stage III (Exacerbation) occurs when a new roentgenographic infiltrate occurs associated with elevation of total serum IgE. Stage IV (Corticosteroid-Dependent Asthma) is present when repeated attempts to discontinue prednisone results in severe wheezing that cannot be prevented with other therapy. Some Stage IV patients continue to develop new ABPA infiltrates. Stage V (Fibrotic) patients have irreversible obstructive and restrictive pulmonary function abnormalities and may present or progress to respiratory failure and death.

Use of linear tomography to confirm the diagnosis of allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) has been recognized increasingly in the past few years. In minimal disease, plain chest films may be insensitive. Early detection of pulmonary involvement may help prevent irreversible damage to the lungs and bronchi. Bronchography, while both sensitive and specific, is not without hazard, particularly to the asthmatic patient. We evaluated the usefulness of linear tomography in confirming ABPA prior to initiation of corticosteroid therapy. We find that tomography is a simple, noninvasive instrument for detecting the presence of or proving the absence of the earliest manifestations of ABPA.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) occurs as a complication of asthma. It presents as an infiltrative pulmonary disorder with respiratory and systemic symptoms, eosinophilia, elevated total serum IgE, and skin sensitizing, as well as precipitating antibodies to Aspergillus fumigatus. Sputum cultures are not always positive for the organism. If unchecked, the disease may lead to bronchiectasis and ultimately pulmonary fibrosis. Therapy consists mainly of corticosteroids.

Late sequelae of allergic bronchopulmonary aspergillosis

Seven patients with late sequelae of allergic bronchopulmonary aspergillosis (ABPA) are described. All seven had significant chronic symptoms from asthma. At the time of diagnosis of ABPA all patients had marked irreversible pulmonary function abnormalities; symptoms of chronic bronchitis were present in all. Pulmonary fibrosis was present in six of seven patients. Three patients have died from irreversible lung disease with terminal cardiac failure. Despite the difficulty in establishing an early diagnosis of ABPA, its importance must be emphasized in order to attempt to prevent progression of the disease to severe irreversible and potentially fatal end-stage lung disease.

Allergic bronchopulmonary aspergillosis complicating cystic fibrosis in childhood

Allergic bronchopulmonary aspergillosis, known to be associated with cystic fibrosis in older patients, occurred in 7 young atopic children with cystic fibrosis. The diagnosis was suggested by the onset of, or the increase in, asthmatic symptoms accompanied by major chest x-ray changes ranging from total collapse of a lung or lobe to extensive but changing areas of consolidation. Each of the children had a blood eosinophilia, positive type I skin tests to Aspergillus fumigatus, and reversible airways obstruction. Most had a positive type III skin test and circulating precipitins to A. fumigatus, with raised IgE levels which contained specific antibodies to the fungus on radioallergosorbent (RAST) test. None had advanced suppurative chest disease of cystic fibrosis. None was given specific antifungal agents; two received systemic treatment with corticosteroids, the other received additional drugs for their asthma. Two developed total collapse of one lung, one child being only 2 years old. Five have had recurrences of pulmonary shadowing typical of allergic aspergillosis but are not showing significant progression of their cystic fibrosis lung disease. Our experience suggests that there should be an increased awareness of this condition, particularly its association with extensive pulmonary collapse or consolidation in children with cystic fibrosis who are atopic.

A guide to the recent literature on aspergillosis as caused by Aspergillus fumigatus, a fungus frequently found in self-heating organic matter

Spores of Aspergillus fumigatus have been found to be abundantly present in the outdoor air at a site where large scale experimental composting of sewage sludge is in progress at Beltsville, Maryland. The health significance of this finding, for that site and for others in the future, is still only incompletely understood. Further studies are in progress to characterize absolute concentrations of the spores of the fungus in air at the site, spore dispersal by air from composting operations, and background environmental spore levels in air. The present paper contains a list of references to papers on health effects of A. fumigatus, many published in the past ten years, along with a review of the same designed to assist the reader in finding information on particular aspects of the subject in the literature. It is intended primarily as an aid to individuals interested in sludge composting and wishing to attain an insight into the A. fumigatus-composting situation, but it may also interest others concerned with other substrates which become moldy at 40--50 C. A. fumigatus has been found in great numbers in naturally and artificially heated environments such as decaying leaves, compost heaps, solar heated sloughs, cooling canals for nuclear power generators, silos, grain storage bins, boiler rooms, detritus around steam turbines and sauna baths. The evident practical merits of sludge composting have been described elsewhere; the information presented here has its main significance in respect to requirements for choice of locations for composting sites and to process and design criteria.

The assessment of immunologic and clinical changes occurring during corticosteroid therapy for allergic bronchopulmonary aspergillosis

Twenty-two patients with allergic bronchopulmonary aspergillosis have been treated and evaluated for a period ranging from two months to nine years. Twelve are available for periodic blood sampling. Data are presented suggesting the following: (1) Patients with allergic bronchopulmonary aspergillosis have high initial levels of total serum immunoglobulin E (IgE). These levels are significantly higher in those patients who had not been previously treated with prednisone for the control of asthma. (2) Treatment with alternate day prednisone (0.5 mg/kg given on alternate days) caused clinical and roentgenologic improvement as well as marked decreases in total serum IgE but does not necessarily prevent recurrence of the disease. (3) Total and specific IgE against Aspergillus antigen may increase prior to and during exacerbations of disease. (4) Specific IgG and IgE against Aspergillus antigen are increased in most patients with allergic bronchopulmonary aspergillosis and reflect disease activity as evidenced by x-ray and clinical exacerbations in some cases. (5) Lymphocyte transformation using Aspergillis antigen, as measured by the whole blood technic, is present in patients with allergic bronchopulmonary aspergillosis, but serial changes in lymphocyte transformation do not correlate with disease activity. (6) Precipitin reactions are present in patients with allergic bronchopulmonary aspergillosis, but presence or absence does not reflect disease activity in most cases.