Allergic bronchopulmonary aspergillosis: A review of 42 patients from a tertiary care center in India

Occupational Lung Disease Causing Allergic Bronchopulmonary Aspergillosis: A Case Report

Aspergillus fumigatus can induce allergic bronchopulmonary aspergillosis (ABPA), an immunological hypersensitivity reaction that frequently exacerbates the symptoms of cystic fibrosis and asthma patients. Due to persistent symptoms, a considerable percentage of patients with ABPA in India, a country where tuberculosis is widespread, are initially misdiagnosed as having pulmonary tuberculosis. We present a case of ABPA in a male industry worker, who was diagnosed after one year of having symptoms and has successfully recovered since.

Subacute invasive pulmonary aspergillosis in a nondiabetic immunocompetent female suffering from allergic broncho pulmonary aspergillosis

A 55-year-old female presented with recent exacerbation of the chronic cough, dyspnea, and copious expectoration. The symptoms worsened during the winter months. In the past, she was misdiagnosed with pulmonary tuberculosis. A computed tomography scan revealed bronchiectasis changes, high attenuated mucus, and hypereosinophilia. The diagnosis of Allergic Bronchopulmonary Aspergillosis (ABPA) with subacute invasion was confirmed through bronchoscopy and fungal culture. Treatment with oral voriconazole significantly improved lung function and quality of life. This case highlights the importance of considering invasive pulmonary aspergillosis in patients with exacerbations of asthma and bronchiectasis. Early diagnosis and appropriate treatment are essential for improved outcomes in such cases.

Clinical, Microbiological, Serological and Radiological Profile of Patients With Mild-Moderate and Severe Allergic Bronchopulmonary Aspergillosis (ABPA)

Objective Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction to Aspergillus antigen mostly Aspergillus fumigatus that occurs almost exclusively in patients with asthma and cystic fibrosis. ABPA is an underdiagnosed and undertreated disease because of its presentation with various grades of severity in asthma patients. Data available regarding the clinical, serological, and radiological profile of ABPA patients is limited due to lack of consensus on diagnostic criteria and treatment guidelines. Thus ABPA is a significant disease, especially in the Indian population where the incidence of allergic diseases like asthma is on the rise. Methods This prospective study was conducted in the Department of Pulmonary Medicine at one of the tertiary centers of north India. All consecutive patients diagnosed with allergic bronchopulmonary aspergillosis (ABPA) from 1st January 2017 to 30th September 2017 were included in the study. A total of 67 consecutive patients diagnosed with bronchial asthma were included in the study. The diagnosis of ABPA was based upon either criterion given by Rosenberg and Paterson or the International Society of Human and Animal Mycology (ISHAM) criteria. Patients diagnosed with ABPA were finally divided into mild, moderate, and severe. Results The majority of patients showed an obstructive pattern on spirometry and moderate to severe obstruction was the most common pattern observed among patients who had an obstructive pattern on spirometry. Also, all three patients with the mixed pattern on spirometry had severe disease. Serological analysis revealed that patients in the moderate category had a higher level of absolute eosinophil count (AEC), total IgE, and Aspergillus-specific IgE antibodies, especially in patients who had either high attenuation mucus (HAM) or centrilobular nodules on their high-resolution computed tomography (HRCT) scan. Conclusion ABPA is a disease of divergent presentation. We concluded to have alternate or add-on criteria for the classification of ABPA which was not based on the sequelae of chronic inflammatory changes in the lungs.

The Clinical Characteristics of Allergic Bronchopulmonary Mycosis Differ Among Pathogenic Fungi

Background

Allergic bronchopulmonary mycosis (ABPM) occurs with fungi, other than Aspergillus fumigatus. However, the clinical characteristics of ABPM caused by non-Aspergillus species are unspecified.

Methods

We retrospectively reviewed all patients with ABPM who visited to our hospital between April 2005 and December 2020. The causative fungi and clinical characteristics were analyzed. Patients were divided into the Aspergillus group and the non-Aspergillus group.

Results

Fourteen patients and five patients were included in the Aspergillus group and the non-Aspergillus group, respectively. Compared to the Aspergillus group, the non-Aspergillus group had a significantly low serum immunoglobulin E level and low forced vital capacity. In addition, the non-Aspergillus group had a lower rate of the requirement for oral corticosteroid treatment and a low frequency of recurrence.

Conclusion

Patients with non-Aspergillus ABPM had lower type 2 inflammation than did patients with allergic bronchopulmonary aspergillosis.

An Interesting Case of Allergic Bronchopulmonary Aspergillosis Resulting in Type II Respiratory Failure

Aspergillus fumigatus can cause an immunological hypersensitivity reaction known as allergic bronchopulmonary aspergillosis (ABPA), which often worsens asthma and cystic fibrosis patients’ conditions. In India, where tuberculosis (TB) is endemic, a significant proportion of allergic bronchopulmonary aspergillosis (ABPA) patients are misdiagnosed as pulmonary TB before reaching a diagnosis of ABPA due to long-lasting symptoms. We discuss an uncommon presentation of ABPA with type II respiratory failure in a 48-year-old asthmatic female. Given this, one can speculate on the importance of ABPA presenting with respiratory failure since these cases are rare and diagnosed quite late, which can also prove fatal.

"Allergic bronchopulmonary aspergillosis misdiagnosed as smear negative pulmonary tuberculosis; a retrospective study from Pakistan"

Background

Undiagnosed allergic bronchopulmonary aspergillosis (ABPA) can lead to chronic persistent symptoms. In country like Pakistan where tuberculosis (TB) is endemic, a significant proportion of ABPA patients are misdiagnosed as smear negative TB before reaching a diagnosis of ABPA due to chronicity of symptoms.This lead to empiric use of ATT(Anti-tuberculous therapy) and delay in primary diagnosis. The aim of the study is to determine such proportion of ABPA patients.

Material and methods

This retrospective study was conducted at the outpatient pulmonology clinic of a tertiary care hospital in Karachi, Pakistan from January 2017 to December 2018. Xpert MTB/Rif, TB smear and culture were performed in all patients to rule out active TB.

Results

A total 167 of ABPA patients were included. Mean age of the patients was 41.9 ± 13.0 years, 91(54.5%) were female and 71 (42.5%) patients had received ATT in past. Out of these 71 patients, 63 (88.7%) patients were diagnosed as smear negative TB and received empiric ATT. Among 63 patients, 52 (82.5%) patient had received ATT once, 8 (12.6%) twice and 3 (4.7%) patients had received empiric ATT thrice. Of these 27 (16.16%) patients had already developed long term complications at the time of diagnosis of ABPA and 17 (62.96%) patients were in empiric TB treatment group.

Conclusion

Patient with ABPA frequently received empiric ATT as smear negative TB in high TB burden country. This results in over diagnosis of TB and unnecessary use of global resource. When Gene Xpert negative alternate diagnosis should be considered.

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Allergic bronchopulmonary aspergillosis (ABPA) can lead to chronic persistent symptoms.

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In country like Pakistan where tuberculosis (TB) is endemic, a significant proportion of ABPA patients are misdiagnosed as smear negative TB before reaching a diagnosis of ABPA due to chronicity of symptoms which leads to empiric use of ATT.

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So the aim of the study is to determine such proportion of ABPA patients in country where TB is endemic.

Allergic Broncho-Pulmonary Aspergillosis

Allergic broncho-pulmonary aspergillosis (ABPA) is an immunologically mediated lung disease that usually occurs in people with a diagnosis of asthma or cystic fibrosis. It is a noninvasive lung disease caused by colonization of the airways with Aspergillus fumigatus. In people who are susceptible, Aspergillus leads to an exaggerated immune response and ultimately pulmonary inflammation and lung damage. Patients with ABPA typically present with poorly controlled asthma, recurrent pulmonary infiltrates, and bronchiectasis. Diagnosis of ABPA is established based on a combination of clinical manifestations as well as laboratory and radiological evaluations. Delay in diagnosis can result in airway destruction and pulmonary fibrosis, which may result in significant morbidity and mortality. This article discusses the clinical characteristics, diagnosis, and management of patients with ABPA. It aims to serve as a tool for pediatricians to aid in early recognition of this debilitating disease and consider referral, facilitating early diagnosis and treatment. [Pediatr Ann. 2021;50(5):e214-e221.].

Diagnosis of allergic bronchopulmonary aspergillosis in patients with persistent allergic asthma using three different diagnostic algorithms

BACKGROUND

Allergic bronchopulmonary aspergillosis (ABPA) has been reported in various degrees among patients with persistent allergic asthma (PAA). Currently, there is no gold standard approach for diagnosis of ABPA.

OBJECTIVES

In the current study, we aimed the evaluation of three different mainly used algorithms as Rosenberg & Patterson (A), ISHAM Working Group (B) and Greenberger (C) for diagnosis of ABPA in 200 patients with underlying PAA.

METHODS

All patients were evaluated using Aspergillus skin prick test (SPTAf), Aspergillus-specific IgE (sIgEAf) and IgG (sIgGAf), total IgE (tIgE), pulmonary function tests, radiological findings and peripheral blood eosinophil count. The prevalence rate of ABPA in PAA patients was estimated by three diagnostic criteria. We used Latent Class Analysis for the evaluation of different diagnostic parameters in different applied ABPA diagnostic algorithms.

RESULTS

Aspergillus sensitisation was observed in 30 (15.0%) patients. According to algorithms A, B and C, nine (4.5%), six (3.0%) and 11 (5.5%) of patients were diagnosed with ABPA, respectively. The sensitivity and specificity of criteria B and C were (55.6% and 99.5%) and (100.0% and 98.9%) respectively. sIgEAf and sIgGAf showed the high significant sensitivity. The performance of algorithm A, in terms of sensitivity and specificity, was somewhat better than algorithm B.

CONCLUSION

Our study demonstrated that the sensitivity of different diagnostic algorithms could change the prevalence rate of ABPA. We also found that all of three criteria resulted an adequate specificity for ABPA diagnosis. A consensus patterns combining elements of all three criteria may warrant a better diagnostic algorithm.

Correlation of asthma severity, IgE level, and spirometry results with HRCT findings in allergic bronchopulmonary aspergillosis

Context

Few studies have been done for correlating asthma severity, IgE level, and spirometry results with high-resolution computed tomographic (HRCT) findings in allergic bronchopulmonary aspergillosis (ABPA).

Aims

This prospective observational study was conducted to correlate asthma severity, IgE level, and spirometry results with HRCT findings in ABPA.

Settings and Design

Prospective observational.

Subjects and Methods

Fifty consecutive adult patients with asthma and positive specific IgE (>0.35 kUA/L) to Aspergillus fumigatus were recruited from October 2015 to July 2017. Asthma severity, IgE levels, and spirometry results were correlated with HRCT score, bronchiectasis score, air trapping segments, and low-attenuation lung volume on inspiratory CT and expiratory CT.

Statistical Analysis Used

One way ANOVA, Spearman's correlation coefficients.

Results

Asthma severity showed a significant positive correlation with HRCT score and bronchiectasis score. MEF pre and postbronchodilator values showed a significant negative correlation with HRCT score, bronchiectasis score, and percentage expiratory volumes -851 to -950 HU voxels. FEV1 prebronchodilator value showed a significant negative correlation with percentage expiratory volume -851 to -950 HU voxels and percentage expiratory volume -851 to -1024 HU voxels. Specific IgE antibody level showed a significant positive correlation with bronchiectasis score.

Conclusions

Asthma severity, specific IgE level, and MEF values showed a good correlation with HRCT findings. The restrictive pattern is common on spirometry in patients of ABPA. In addition to central bronchiectasis, peripheral bronchial and small airway involvement was an important finding in ABPA. Expiratory HRCT may reveal air trapping in patients having no abnormality on inspiratory CT.

Current Approach in the Diagnosis and Management of Allergic Bronchopulmonary Aspergillosis in Children With Cystic Fibrosis

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.

Allergic bronchopulmonary mycosis - pathophysiology, histology, diagnosis, and treatment

Allergic bronchopulmonary mycosis (ABPM) develops mainly in patients with asthma or cystic fibrosis via types I and III hypersensitivity reactions to filamentous fungi. Aspergillus spp., especially Aspergillus fumigatus, is the major causative fungus because of its small conidia, thermophilic hyphae, and ability to secrete serine proteases. The cardinal histological feature of ABPM is allergic (eosinophilic) mucin-harboring hyphae in the bronchi, for which the formation of extracellular DNA trap cell death (ETosis) of eosinophils induced by viable fungi is essential. Clinically, ABPM is characterized by peripheral blood eosinophilia, increased IgE levels in the serum, IgE and IgG antibodies specific for fungi, and characteristic radiographic findings; however, there are substantial differences in the clinical features of this disease between East and South Asian populations. Systemic corticosteroids and/or antifungal drugs effectively control acute diseases, but recurrences are quite common, and development of novel treatments are warranted to avoid adverse effects and emergence of drug-resistance due to prolonged treatment with corticosteroids and/or antifungal drugs.

Prevalence of allergic bronchopulmonary aspergillosis in asthmatic patients: A prospective institutional study

BACKGROUND

Allergic bronchopulmonary aspergillosis (ABPA) is characterized by an allergic inflammatory response to colonization by Aspergillus species, most commonly Aspergillus fumigatus.

AIM

To study the prevalence of ABPA in asthmatic patients presenting to our institute.

MATERIALS AND METHODS

All consecutive asthma patients attending our allergy clinic Out Patient Department (OPD) over a period of 20 months were tested with skin prick test (SPT) for Aspergillus antigens and those who were found positive were further evaluated for ABPA using Greenberger's criteria.

RESULTS

Seventy consecutive asthmatic patients were screened by SPT using Aspergillus antigens. Thirteen patients (18.57%) were found to be SPT positive, out of which nine patients (12.9%) were diagnosed as having ABPA using Greenberger's criteria. ABPA was common among 25-35 age group with no gender predilection. ABPA patients had longer duration of illness, predominantly mixed pattern in PFT, higher mean absolute eosinophil count (AEC) and serum total IgE compared to non-ABPA asthmatic patients. Specific IgE for A. fumigatus was positive in all ABPA patients and serum precipitins were positive in seven patients (77.58%). Chest X-ray abnormalities were seen in five patients (55.6%) and HRCT showed central bronchiectasis in eight patients (88.9%) with varying other radiological features. None were sputum fungal culture positive and five patients (55.6%) have been misdiagnosed as pulmonary tuberculosis in the past.

CONCLUSION

The prevalence of ABPA is significantly higher in bronchial asthma patients presenting to tertiary care centers and hence awareness is required among physicians for early diagnosis and management of ABPA to achieve better asthma control and to avoid permanent lung damage.

Allergic bronchopulmonary aspergillosis: A clinical review of 24 patients: Are we right in frequent serologic monitoring?

BACKGROUND:

Allergic Broncho Pulmonary Aspergillosis (ABPA) is a rare disease characterized by an allergic inflammatory response to the colonization by aspergillus or other fungi in the airways. The aim was to study the clinical, radiological, and serological characteristics of patients of ABPA.

MATERIALS AND METHODS:

A prospective observational study of patients with breathlessness, chronic cough, blood eosinophilia, and infiltrates on chest X-ray were evaluated with serologic and allergic skin fungal tests using 15 common fungal antigens. Total of 24 patients were diagnosed as ABPA.

RESULTS:

Total 24 patients, 15 males (62%), 9 females (38%). Age range: 14-70 years, mean 49.13, standard deviation (SD) 14.12. Central bronchiectasis — sixteen patients, bronchocoele — one patient, consolidation — five patients, collapse with mucous plugging with areas of consolidation — three patients, one patient had bronchiectasis, consolidation with hemorrhagic pleural effusion. Fifty-eight percent of patients had received anti-tuberculosis medications prior to diagnosis. Serum total IgE varied from 340 to 18100 IU/mL. Two patients had IgE levels below 1,000 IU/mL. The mean decrease in Serum total IgE levels at the end of 1 month was 26.1% (range: 0.7-71.9%) and at the end of 2 months was 58.9% (range: 11.11-93.26%) (P value of 0.004). Two patients had skin sensitivity to fungal antigens other than aspergillus species.

CONCLUSION:

ABPA is a disease with varied clinical, radiological, and serological patterns. Serum IgE monitoring may be done at the end of 2 and 6 months. Further studies are required to simplify the diagnosis and treatment algorithms in resource-limited countries.

Management of allergic bronchopulmonary aspergillosis: a review and update

Since the first description of allergic bronchopulmonary aspergillosis (ABPA) in the 1950s there have been numerous studies that have shed light on the characteristics and immunopathogenesis of this disease. The increased knowledge and awareness have resulted in earlier diagnosis and treatment of patients with this condition. This article aims to provide a summary and updates on ABPA by reviewing the results of recent studies on this disease with a focus on articles published within the last 5 years. A systematic search of PubMed/Medline with keywords of ABPA or allergic bronchopulmonary aspergillosis was performed. All selected articles were reviewed with a focus on findings of articles published from December 2006 to December 2011. The relevant findings are summarized in this paper.

Serum level of specific IgG antibody for aspergillus and its association with severity of asthma in asthmatic children

Aspergillosis is one of the frequent causes of exacerbation of asthma depending on the geographical regions. The specific serum IgG level for aspergillus is a major diagnostic criterion in aspergillosis.Ninety-six asthmatic patients, with mean age of 5.4 ± 3.0 years who were referred to the asthma clinic of the Mofid Children's Hospital, were enrolled in this study. Serum specific IgG for aspergillus was measured and its association with severity of asthma was evaluated.Nineteen asthmatic patients (10 females and 9 males) had aspergillus IgG antibody. Among them, severe persistent asthma and moderate persistent asthma were detected in 5 and 13 cases, respectively, whereas only one patient suffered from mildpersistent asthma. A total of 36.5% of the 96 patients had a history of atopy, while 26% had allergic rhinitis. There was an association between the severity of asthma and the presence of aspergillus IgG antibody. Moreover, the positivity for aspergillus IgG antibody was higher in older patients.Our results indicated an association between aspergillus antibody level and severity of asthma. It could be recommended that the IgG titer for aspergillus is measured in pediatric patients with asthma, whereas co-morbidity of aspergillosis and asthma increases the risk of asthma exacerbation.