Chronic Pulmonary Aspergillosis in Patients with Underlying Respiratory Disorders in Cuba-A Pilot Study

Chronic pulmonary aspergillosis: comprehensive insights into epidemiology, treatment, and unresolved challenges

Chronic pulmonary aspergillosis (CPA) is a challenging respiratory infection caused by the environmental fungus Aspergillus. CPA has a poor prognosis, with reported 1-year mortality rates ranging from 7% to 32% and 5-year mortality rates ranging from 38% to 52%. A comprehensive understanding of the pathogen, pathophysiology, risk factors, diagnosis, surgery, hemoptysis treatment, pharmacological therapy, and prognosis is essential to manage CPA effectively. In particular, Aspergillus drug resistance and cryptic species pose significant challenges. CPA lacks tissue invasion and has specific features such as aspergilloma. The most critical risk factor for the development of CPA is pulmonary cavitation. Diagnostic approaches vary by CPA subtype, with computed tomography (CT) imaging and Aspergillus IgG antibodies being key. Treatment strategies include surgery, hemoptysis management, and antifungal therapy. Surgery is the curative option. However, reported postoperative mortality rates range from 0% to 5% and complications range from 11% to 63%. Simple aspergilloma generally has a low postoperative mortality rate, making surgery the first choice. Hemoptysis, observed in 50% of CPA patients, is a significant symptom and can be life-threatening. Bronchial artery embolization achieves hemostasis in 64% to 100% of cases, but 50% experience recurrent hemoptysis. The efficacy of antifungal therapy for CPA varies, with itraconazole reported to be 43-76%, voriconazole 32-80%, posaconazole 44-61%, isavuconazole 82.7%, echinocandins 42-77%, and liposomal amphotericin B 52-73%. Combinatorial treatments such as bronchoscopic triazole administration, inhalation, or direct injection of amphotericin B at the site of infection also show efficacy. A treatment duration of more than 6 months is recommended, with better efficacy reported for periods of more than 1 year. In anticipation of improvements in CPA management, ongoing advances in basic and clinical research are expected to contribute to the future of CPA management.

Fungal Infections in the Caribbean: A Review of the Literature to Date

The most common fungal infections reported from the Caribbean include dermatophytosis, candidiasis, pneumocystis, aspergillosis, histoplasmosis, and cryptococcosis. The Caribbean is hyperendemic for histoplasmosis, with high population exposures. Fungal infections are a significant public health problem in the Caribbean, with rates varying depending on the specific country or region. In Trinidad and Tobago, the fungal burden accounts for 3.3% of the 1.4 million population, while in Jamaica, with a population of 2.9 million, over 57,600 people suffer from fungal infections each year. A study in the Dominican Republic estimated that approximately 221,027 (2%) of over 10 million people have a serious fungal infection. Fungal infections accounts for 21.9% of all skin infections in Haiti. The diagnosis of fungal infections in the Caribbean can be challenging, as access to laboratory testing and specialized medical services is limited in many areas. Access to antifungal medications can also be a challenge in some areas, and antifungal resistance has been reported.

Genomic and Phenotypic Trait Variation of the Opportunistic Human Pathogen Aspergillus flavus and Its Close Relatives

Fungal diseases affect millions of humans annually, yet fungal pathogens remain understudied. The mold Aspergillus flavus can cause both aspergillosis and fungal keratitis infections, but closely related species are not considered clinically relevant. To study the evolution of A. flavus pathogenicity, we examined genomic and phenotypic traits of two strains of A. flavus and three closely related species, Aspergillus arachidicola (two strains), Aspergillus parasiticus (two strains), and Aspergillus nomiae (one strain). We identified >3,000 orthologous proteins unique to A. flavus, including seven biosynthetic gene clusters present in A. flavus strains and absent in the three nonpathogens. We characterized secondary metabolite production for all seven strains under two clinically relevant conditions, temperature and salt concentration. Temperature impacted metabolite production in all species, whereas salinity did not affect production of any species. Strains of the same species produced different metabolites. Growth under stress conditions revealed additional heterogeneity within species. Using the invertebrate fungal disease model Galleria mellonella, we found virulence of strains of the same species varied widely; A. flavus strains were not more virulent than strains of the nonpathogens. In a murine model of fungal keratitis, we observed significantly lower disease severity and corneal thickness for A. arachidicola compared to other species at 48 h postinfection, but not at 72 h. Our work identifies variations in key phenotypic, chemical, and genomic attributes between A. flavus and its nonpathogenic relatives and reveals extensive strain heterogeneity in virulence that does not correspond to the currently established clinical relevance of these species. IMPORTANCE Aspergillus flavus is a filamentous fungus that causes opportunistic human infections, such as aspergillosis and fungal keratitis, but its close relatives are considered nonpathogenic. To begin understanding how this difference in pathogenicity evolved, we characterized variation in infection-relevant genomic, chemical, and phenotypic traits between strains of A. flavus and its relatives. We found extensive variation (or strain heterogeneity) within the pathogenic A. flavus as well as within its close relatives, suggesting that strain-level differences may play a major role in the ability of these fungi to cause disease. Surprisingly, we also found that the virulence of strains from species not considered to be pathogens was similar to that of A. flavus in both invertebrate and murine models of disease. These results contrast with previous studies on Aspergillus fumigatus, another major pathogen in the genus, for which significant differences in infection-relevant chemical and phenotypic traits are observed between closely related pathogenic and nonpathogenic species.

Prevalence of chronic pulmonary aspergillosis regarding time of tuberculosis diagnosis in Brazil

BACKGROUND

Data on the prevalence of chronic pulmonary aspergillosis (CPA) in patients with active or cured tuberculosis (TB) are scarce, mainly due to diagnostic difficulties. The diagnosis of CPA is based on pulmonary symptoms and chest computed tomography (CT) scans and is considered confirmed when there is microbiological or serological evidence of Aspergillus spp.

INFECTION

OBJECTIVES

To estimate the prevalence of CPA in patients treated or undergoing treatment for PTB, seen in two referral hospitals in Mato Grosso do Sul, Brazil.

PATIENTS AND METHODS

A total of 193 consecutive patients who were treated or previously treated for pulmonary tuberculosis underwent prospective evaluation: a) clinical evaluation; b) chest CT scan; c) sputum examination-culture for fungi and smears for direct mycology; d) detection of anti-Aspergillus fumigatus antibodies using an enzyme-linked immunosorbent assay Platelia® test; and e) anti-Aspergillus spp. antibodies were assessed via a DID test.

RESULTS

The global prevalence of CPA was 10.9% (95% confidence interval, 7.2-16.1%), but it increased with the time of TB diagnosis. The variables independently associated with CPA were previous pulmonary tuberculosis over 4 years ago and hemoptysis. Cavities, pleural thickening, and the presence of a fungal ball were the most frequent tomographic findings in patients with CPA.

CONCLUSIONS

The high prevalence observed and its increase over time suggest the need for continuous surveillance of CPA in patients with active or previous pulmonary tuberculosis and throughout life, with clinical, tomographic, and serological evaluations (ELISA) for a timely diagnosis and a better prognosis.

Chronic Pulmonary Aspergillosis Situation among Post Tuberculosis Patients in Vietnam: An Observational Study

This study provides a brief view of chronic pulmonary aspergillosis (CPA) in the post-tuberculosis treatment community in Vietnam, a high burden tuberculosis (TB) country. In three months in late 2019, 70 post-TB patients managed at Vietnam National Lung Hospital were enrolled. Of these, 38 (54.3%) had CPA. The male/female ratio was 3/1 (28 males and ten females). CPA patients had a mean age of 59 ± 2.3 years (95%CI 54.4-63.6). The mean Body mass index (BMI) was 19.0 ± 0.5 (18.0-20.0) and 16 of 38 (42.1%) patients had concurrent diseases, the most common of which were chronic obstructive pulmonary disease (COPD) and diabetes. Twenty-six patients (68.4%) developed hemoptysis, 21 (55.3%) breathlessness, and weight loss was seen in 30 (78.9%). Anaemia was seen in 15 (39.5%) and 27 of 38 (71.1%) patients had an elevated C-reactive protein (CRP). The most common radiological findings were multiple cavities (52.6%) and pleural thickening (42.7%), followed by aspergilloma (29.0%) and non-specific infiltrates. There were five of 38 patients (13.2%) with a cavity containing a fungal ball on the chest X-ray, but when the high resolution computed tomography (HRCT) was examined, the number of patients with fungal balls rose to 11 (28.9%). Overall, 34 of 38 (89.5%) cases had an elevated Aspergillus IgG with an optical density ≥ 1, and in 2 cases, it was 0.9-1.0 (5%), borderline positive. In nine patients (23.7%) Aspergillus fumigatus was cultured from sputum. CPA is an under-recognised problem in Vietnam and other high burden TB countries, requiring a different diagnostic approach and treatment and careful management. HRCT and Aspergillus IgG serum test are recommended as initial diagnostic tools for CPA diagnosis.

Phylogenetic Identification, Diversity, and Richness of Aspergillus from Homes in Havana, Cuba

Aspergillus is one of the most common fungal genera found indoors; it is important because it can cause a wide range of diseases in humans. Aspergillus species identification is based on a combination of morphological, physiological, and molecular methods. However, molecular methodologies have rarely been used for the identification of environmental isolates of Aspergillus in Cuba. Therefore, the objective of this work was to identify the species of the genus Aspergillus obtained from houses in Havana, Cuba, through the construction of phylogeny from a partial sequence of the benA gene region, and to analyze the diversity and richness of Aspergillus in the studied municipalities. Isolates of Aspergillus spp. included in this study presented the typical macro- and micromorphology described for the genus. According to this polyphasic characterization, A. niger, A. flavus, A. welwitschiae, A. heteromorphus, A. sydowii, A. tamarii, A. fumigatus, A. clavatus, and A. tubingensis were the most abundant species. Most of the identified species constitute new records for outdoor and indoor environments in Cuba and contribute to the knowledge of fungal biodiversity in the country. These results constitute an alert for the health authorities of the country, since prolonged exposure of the inhabitants to Aspergillus spores can cause severe persistent asthma, among other diseases.

Diagnostic cut-off value for Aspergillus fumigatus- and flavus-specific IgG with clinical relevance in chronic pulmonary Aspergillus infection: A pilot study in Taiwan

BACKGROUND

The diagnostic cut-off value for chronic pulmonary Aspergillosis (CPA) by Aspergillus fumigatus-specific IgG has never been evaluated In Taiwan. The cut-off value for Aspergillus flavus-specific IgG has not been evaluated worldwide.

OBJECTIVES

Evaluate diagnostic cut-off value of Aspergillus IgG and its application characteristics.

PATIENTS/METHODS

Blood from control groups and treatment-naïve patients with CPA infections was collected for Aspergillus-specific IgG measurements. Controls were patients who had chest radiographic abnormalities and signs of respiratory tract infection, but were negative for Aspergillus and resolved without anti-mould therapy. Confirmation and probability of CPA were defined according to radiological features and positivity for an Aspergillus or galactomannan index. Chest computer tomography patterns were recorded for the presence of aspergilloma or nodules, subacute invasive aspergillosis, chronic cavitary pulmonary aspergillosis and chronic fibrotic pulmonary aspergillosis.

RESULTS

A total of 35 cases and 50 disease controls were included. The levels of A. fumigatus- and A. flavus-specific IgG correlated with CPA progression (P < .05) but not with the presence of Aspergillus species from clinical specimens (P > .05). The best cut-off value for A. fumigatus IgG was 21.7 mg/L with area under curve (AUC) for receiver operating characteristic curve (ROC) 0.934 and had 85.7% sensitivity and 92.0% specificity. For A. flavus IgG, the best cut-off value was 22.1 mgA/L and the AUC was 0.928 with 88.2% sensitivity and 94.1% specificity.

CONCLUSION

The level of Aspergillus-specific IgG correlated with radiographic characteristics in patients with CPA and the best cut-off values compared to controls were 21.7 mgA/L for A. fumigatus-specific IgG and 22.1 mgA/L for A. flavus-specific IgG.

Underlying Conditions and Clinical Spectrum of Chronic Pulmonary Aspergillosis (CPA): An Experience from a Tertiary Care Hospital in Karachi, Pakistan

The incidence of chronic pulmonary aspergillosis (CPA) is especially increasing in high tuberculosis (TB) burden countries. Despite a high estimated CPA burden in Pakistan, actual data on CPA are not available. The aim of the current study is to determine the underlying conditions and clinical spectrum of CPA at a tertiary care hospital in Karachi, Pakistan. This is a retrospective chart review study in patients admitted with CPA from January 2012 to December 2017. A total of 67 patients were identified during the study period. Mean age of CPA patients was 45.9 ± 15 years, 44 (65.7%) were male and 19 (28.4%) had diabetes. The most common type of CPA was simple aspergilloma (49.2%) followed by chronic cavitary pulmonary aspergillosis (CCPA) (44.7%). TB was the underlying cause of CPA in 58 (86.6%) patients followed by bronchiectasis caused by allergic bronchopulmonary aspergillosis (ABPA) 8 (11.9%). Aspergillus flavus was identified in 17 (47.2%), followed by A. fumigatus in 13 (36.1%) CPA patients. Isolation of multiple Aspergillus species was found in 10 (25.6%) patients. Itraconazole was given in 27 (40.3%) patients and a combination therapy of itraconazole and surgery was given in 21 (31.34%) patients. We found aspergilloma and CCPA as the most prevalent forms of CPA in our setting. Further large prospective studies using Aspergillus specific immunoglobulin G (IgG) antibodies testing are required for better understanding of CPA in Pakistan.

Evaluation of LDBio Aspergillus ICT Lateral Flow Assay for IgG and IgM Antibody Detection in Chronic Pulmonary Aspergillosis

Detecting Aspergillus-specific IgG is critical to diagnosing chronic pulmonary aspergillosis (CPA). Existing assays are often cost- and resource-intensive and not compatible with resource-constrained laboratory settings. LDBio Diagnostics has recently commercialized a lateral flow assay based on immunochromatographic technology (ICT) that detects Aspergillus antibodies (IgG and IgM) in less than 30 min, requiring minimal laboratory equipment. A total of 154 CPA patient sera collected at the National Aspergillosis Centre (Manchester, United Kingdom) and control patient sera from the Peninsula Research Bank (Exeter, United Kingdom) were evaluated. Samples were applied to the LDBio Aspergillus ICT lateral flow assay, and results were read both visually and digitally. Results were compared with Aspergillus IgG titers in CPA patients, measured by ImmunoCAP-specific IgG assays. For proven CPA patients versus controls, sensitivity and specificity for the LDBio Aspergillus ICT were 91.6% and 98.0%, respectively. In contrast, the routinely used ImmunoCAP assay exhibited 80.5% sensitivity for the same cohort (cutoff value, 40 mg of antigen-specific antibodies [mgA]/liter). The assay is easy to perform but challenging to read when only a very faint band is present (5/154 samples tested). The ImmunoCAP Aspergillus IgG titer was also compared with the Aspergillus ICT test line intensity or rate of development, with weak to moderate correlations. The Aspergillus ICT lateral flow assay exhibits excellent sensitivity for serological diagnosis of CPA. Quantifying IgG from test line intensity measurements is not reliable. Given the short run time, simplicity, and limited resources needed, the LDBio Aspergillus ICT is a suitable diagnostic tool for CPA in resource-constrained settings.