Delayed diagnosis of allergic bronchopulmonary aspergillosis due to absence of asthmatic symptoms

Allergic Bronchopulmonary Aspergillosis With or Without Asthmatic Symptoms?

Allergic bronchopulmonary aspergillosis (ABPA) is a localized inflammatory airway disease seen in patients sensitized to Aspergillus fumigatus (A. fumigatus) antigens. The disease presents with productive cough, wheezing, episodic fever, as well as central bronchiectasis (CB) and mucus plugs on computed tomography (CT) scans. If treated accordingly, symptoms and pulmonary damage caused by ABPA can be reverted. Currently, the diagnostic criteria for ABPA require the diagnosis of predisposing pulmonary diseases such as asthma and cystic fibrosis (CF) in order to establish the diagnosis. There has been an increasing number of cases reporting ABPA without evidence of past asthmatic history or symptoms. This reflects the need for more sensitive diagnostic tests in order to prevent progression to irreversible lung injury. Here we report a 22-year-old Puerto Rican male who went undiagnosed for ABPA for 12 months due to the absence of asthma or CF history.

Clinical characteristics of allergic bronchopulmonary aspergillosis in patients with and without bronchiectasis

OBJECTIVE

Allergic bronchopulmonary aspergillosis (ABPA) is classified radiologically as serologic ABPA (ABPA-S) or ABPA with central bronchiectasis (ABPA-CB). This retrospective case series study aimed to describe and compare the clinical characteristics of both forms of ABPA.

METHODS

Patients with ABPA treated in the hospital between February 2011 and June 2019 were enrolled and were divided into ABPA-S and ABPA-CB groups based on whether their cases were complicated with central bronchiectasis. Demographic data, symptoms, laboratory values, comorbidities, and image findings were collected. ABPA-S patients were followed up retrospectively through medical records.

RESULTS

Ninety-three (93) patients were enrolled, including 74 ABPA-CB patients and 19 ABPA-S patients. The most common predisposing condition was asthma (36.6%), with a median course of 30 years (IQR 13-42.5) prior to ABPA diagnosis. Patients of 54.8% had been misdiagnosed, with ABPA-S more likely than ABPA-CB to have been misdiagnosed as asthma (p < 0.01). Obstructive ventilation dysfunction and mixed ventilation dysfunction were found in 21 patients (22.6%) and 16 patients (17.2%), respectively. Compared with ABPA-S, ABPA-CB had a higher median blood eosinophil count (880 vs. 700 cells/μl), serum IgE (2957 vs. 2616 IU/ml), and Aspergillus fumigatus specific-IgE (20.6 vs. 7.31 kUA/L), although these findings were not statistically significant. Three ABPA-S patients developed bronchiectasis during follow-up and experienced relapses more than twice.

CONCLUSIONS

Our findings suggested that the clinical characteristics between ABPA-CB and ABPA-S were mostly similar. ABPA-S had a relatively lower immunological activity level than ABPA-CB but was still immunologically active and could develop bronchiectasis.

Allergic fungal rhinosinusitis accompanied by allergic bronchopulmonary aspergillosis: A case report and literature review

BACKGROUND

Concomitant allergic fungal rhinosinusitis (AFRS) and allergic bronchopulmonary aspergillosis (ABPA) are extremely rare, with no more than 20 cases reported in the English literature.

CASE SUMMARY

A 52-year-old female patient complained of right-sided nasal obstruction, rhinorrhea, sneezing, epistaxis, and hyposmia for a period of around 5 mo. Nasal examination detected paleness and edema of the nasal mucous membrane and a polyp in the right middle meatus. A computed tomography (CT) scan of the sinuses revealed a ground-glass opacity filling the right maxillary and ethmoid sinuses, along with bone absorption in the medial wall of the right maxillary sinus. Magnetic resonance images were obtained with T1-weighted, T2-weighted, and gadolinium-enhanced T1-weighted sequences. A well-defined mass, located in the right maxillary and ethmoid sinuses and displaying obvious hypointense features, was observed on both T1- and T2-weighted images, with peripheral enhancement on gadolinium-enhanced T1-weighted images. The patient also has a 20-year history of cough and dyspnea. Chest CT revealed columned and cystiform bronchiectasis in the bilateral bronchus, surrounded by a large number of spotted and funicular high-density lesions. The level of serum total IgE was > 5000 kU/L. Serum IgE levels related to house dust and aspergillus showed a positive result, with the values being 3.5 kU/L and 1.2 kU/L. We performed functional endoscopic sinus surgery under local anesthesia. After surgery, topical glucocorticoids and saline irrigation were applied in the nasal cavity until the present time. An oral glucocorticoid (methylprednisolone 16 mg/d) and antifungal agent (itraconazole 200 mg/d) were also used for a period of 4 wk. Montelukast was prescribed at 10 mg/d until the present time. An endoscopic examination showed that the patient was recovering well at 3 mo after surgery.

CONCLUSION

Since different specialists treat ABPA and AFRS, their coexistence may be overlooked. AFRS accompanied by ABPA requires surgical therapy combined with medical control to improve the symptoms.

Misinterpretation of allergic bronchopulmonary aspergillosis/allergic bronchopulmonary mycosis due to diverse characteristics in different clinical stages

Background

Allergic bronchopulmonary mycosis (ABPM) is a complex pulmonary disorder caused by a hyperimmune response to the endobronchial growth of certain fungi. This study aims to aid physicians in better understanding the need for earlier recognition of ABPM.

Methods

Patients with a confirmed diagnosis of ABPM after evaluation were analyzed retrospectively. Clinical features, previous diagnoses and potential diagnostic errors, laboratory findings were reviewed and compiled.

Results

Fifty-seven patients were diagnosed with ABPM in which 22 were misdiagnosed. Eosinophilia was observed in 11 patients and an elevated total serum Ig E level greater than 1,000 kU/L was detected in 25 of the 57 patients. All of the patients were tested for specific Ig E in which positive to different fungi. The two most common abnormalities found on chest high-resolution computed tomography (HRCT) exams were central bronchiectasis and mucus plugs. A mild to moderate obstructive pattern of lung function was observed in 32 cases. By bronchofiberscopic observation, bronchial lumen was seen to have significant inflammation in 12 patients. After 3 weeks of treatment, a decreased serum total Ig E value was observed.

Conclusions

This study highlights the importance of increasing awareness and understanding of non-Aspergillus-ABPM among physicians and draws attention to the need for establishing more elaborate diagnostic criteria for non-Aspergillus-ABPM, which is a rare kind of disease.

The spectrum of pulmonary aspergillosis

Notable progress has been made in the past years in the classification, diagnosis and treatment of pulmonary aspergillosis. New criteria were proposed by the Working Group of the International Society for Human and Animal Mycology (ISHAM) for the diagnosis of allergic bronchopulmonary aspergillosis (ABPA). The latest classification of chronic pulmonary aspergillosis (CPA) suggested by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) has become widely accepted among clinicians. Subacute invasive pulmonary aspergillosis is now considered a type of CPA, yet it is still diagnosed and treated similarly to invasive pulmonary aspergillosis (IPA). Isavuconazole, an extended-spectrum triazole, has recently been approved by the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the treatment of IPA. The most recent Infectious Diseases Society of America (IDSA) guidelines strongly recommend reducing mold exposure to patients at high risk for pulmonary aspergillosis. The excessive relapse rate following discontinuation of therapy remains a common reality to all forms of this semi-continuous spectrum of diseases. This highlights the need to continuously reassess patients and individualize therapy accordingly. Thus far, the duration of therapy and the frequency of follow-up have to be well characterized.