A prospective longitudinal study of chronic pulmonary aspergillosis in pulmonary tuberculosis in Indonesia (APICAL)

Objectives

Chronic pulmonary aspergillosis (CPA) can complicate recovery from pulmonary TB. CPA may also be misdiagnosed as bacteriologically negative TB. This study aimed to determine the incidence of CPA in patients treated for TB in Indonesia, a country with a high incidence of TB.

Methods

In this prospective, longitudinal cohort study in patients treated for pulmonary TB, clinical, radiological and laboratory findings were analysed. Sputum was collected for fungal culture and TB PCR. Patients were assessed at baseline (0–8 weeks) and at the end (5–6 months) of TB therapy. CPA diagnosis was based on symptoms (≥3 months), characteristic radiological features and positive Aspergillus serology, and categorised as proven, probable and possible.

Results

Of the 216 patients recruited, 128 (59%) were followed up until end of TB therapy. At baseline, 91 (42%) had microbiological evidence for TB. Aspergillus-specific IgG was positive in 64 (30%) patients and went from negative to positive in 16 (13%) patients during TB therapy. The incidence rates of proven and probable CPA at baseline were 6% (n=12) and 2% (n=5) and end of TB therapy 8% (n=10) and 5% (n=7), respectively. Six patients (two with confirmed TB) developed an aspergilloma. Diabetes mellitus was a significant risk factor for CPA (p=0.040). Persistent cough (n=5, 50%; p=0.005) and fatigue (n=6, 60%; p=0.001) were the most common symptoms in CPA.

Conclusion

CPA should be considered a relatively frequent differential diagnosis in patients with possible or proven TB in Indonesia. Lack of awareness and limited access to Aspergillus-specific IgG tests and CT imaging are obstacles in establishing a CPA diagnosis.

Gastroesophageal Reflux Disease and Pulmonary Diseases Associated with Aspergillosis: Is There a Connection?

INTRODUCTION

We studied the relationship between GORD and allergic bronchopulmonary aspergillosis (ABPA), chronic pulmonary aspergillosis (CPA), or Aspergillus bronchitis.

BACKGROUND

Gastroesophageal reflux disease (GORD) is well known to initiate or exacerbate pulmonary inflammatory conditions, inducing bronchial asthma and chronic obstructive lung disease.

METHODS

We reviewed four patients referred with elevated Aspergillus serology markers and marked pulmonary symptoms for ABPA, CPA, and Aspergillus bronchitis, and discussed the underlying pathophysiological relationship with GORD. Data were collected retrospectively from medical records included age, gender, predisposing factors for ABPA, chronic pulmonary aspergillosis, or Aspergillus bronchitis; presence of nocturnal reflux, nausea, epigastric pain, Medical Research Council dyspnea scale score, pH manometry data, endoscopic results (ulcers, Barrett's esophagus), treatment of GORD [proton-pump inhibitors (PPIs), surgical operation]; history of smoking, alcohol consumption; concomitant COPD; serological markers (anti-Aspergillus IgG, anti-Aspergillus IgE), and antifungal treatment.

RESULTS

Four patients with GORD were studied; following PPIs administration two achieved clinical improvement. One had ABPA, one CPA, and two had Aspergillus bronchitis; median age was 57 years [range 39-71]; males-to-females ratio was 1:3. Serological markers for aspergillosis were: median total IgE antibodies 573 KIU/L [range 13.1-850], median Aspergillus IgE-specific antibodies 1.2 kAU/L [range <0.4-24.7], and median Aspergillus IgG titers 71 mg/L [range 20-119]. Aspergillus fumigatus grew in one sputum sample.

CONCLUSION

Clinicians caring for patients with gastroesophageal reflux disease presenting with elevated Aspergillus IgG or IgE antibodies should maintain a high index of suspicion for this association and proceed to appropriate evaluations, including laryngoscopy and endoscopy, initiating specific PPI-directed therapy when indicated.