Combined Allergic Bronchopulmonary Aspergillosis and Tropical Pulmonary Eosinophilia: A Rare Co-occurrence

Allergic bronchopulmonary aspergillosis (ABPA) and tropical pulmonary eosinophilia (TPE) are common lung diseases presenting with peripheral blood eosinophilia. Although these have been widely reported both from India and outside, simultaneous co-occurrence of the two diseases has not been reported so far. We hereby present a case of an elderly male, a known case of asthma, who was diagnosed to have concurrent ABPA and TPE. Partial clinical response as well as the persistence of eosinophilia after ABPA treatment raised the suspicion that subsequently led to the diagnosis of TPE. The concurrent treatment of both conditions led to satisfactory clinical and serological improvement.

Spectrum of Aspergillus infections in post TB patients

Background: Fungal colonisation of airways in Post TB patients, can lead to a spectrum of diseases based on the immune response of the host. This study was aimed at studying the different entities of this spectrum. Methods: A cross sectional observational study was conducted over 100 patients of post TB patients to make an observation of the diseases of the spectrum of Aspergillus infections. Results: Of the 100 patients who were studied, IPA was found in 24 (48%), ABPA in 13(26%), CPA in 5(10%) patients out of the 50 diabetics. ABPA in 23 (46%) patients, Simple colonization, CPA in 11(22%) and 4 (8%) patients showed IPA out of the 50 non-diabetics. Conclusion: Chronic pulmonary Aspergillosis was the most common disease from Aspergillus among Post TB patients. Diabetes was associated to invasive forms of Aspergillosis, Invasive Pulmonary aspergillosis (IPA) and subacute invasive pulmonary aspergillosis (SAIA).

Hereditary angioedema and Allergic bronchopulmonary aspergillosis: an unexpected association / Angioedema hereditário e Aspergilose broncopulmonar alérgica: uma associação inesperada

Hereditary angioedema (HAE) is a rare autosomal dominant disorder, Allergic bronchopulmonary aspergillosis (ABPA) is a lung disease involving hypersensitivity to the fungi Aspergillus fumigatus which occur in susceptible patient with asthma or cystic fibrosis, also considered a rare disease. We report a case of HAE and ABPA in a single patient. HAE diagnosis was confirmed: C4 = 3 mg/dL, C1INH < 2.8 mg/dL - nephelometry. Former lung function showed elevation RV and RV/FVC, suggesting small airways lung disease. Positive skin prick test to Aspergillus fumigatus (03 mm); total serum IgE level 3,100 IU/mL (nephelometry - BNII Siemens), eosinophilia 11% (528/mm3) and specific A. fumigatus IgG antibodies 6,8 mgA/L (FEIA - fluorenzymeimmunoassay - ThermoFisher) and Chest CT showed mucoid impaction of the bronchi, consistent to current ABPA. Controlling ABPA could prevent and reduce angioedema attacks, and lung structural damage. Early diagnosis and treatment of both diseases should be emphasized to reduce mortality and morbidity

Angioedema hereditário (AEH) é uma doença autossômica dominante; aspergilose broncopulmonar alérgica (ABPA) é uma doença de hipersensibilidade pulmonar relacionada ao esporo de Aspergillus fumigatus, mais suscetível em pacientes com asma e fibrose cística, ambas são consideradas doenças raras. Apresentamos um caso de AEH e ABPA em um paciente. O diagnóstico de AEH foi confirmado com exames laboratoriais: C4 = 3 mg/dL, C1INH < 2,8 mg/dL - nefelometria. Prova de função pulmonar evidenciou aumento de VR e VR/CVF, sugerindo doenças de pequenas vias aéreas. Teste de puntura positivo para A. fumigatus (03 mm); IgE total = 3.100 IU/mL (nefelometria - BNII Siemens), eosinofilia 11% (528/mm3) e IgG específica para A. fumigatus 6,8 mgA/L (FEIA - ThermoFisher), TC de tórax evidenciou impactação mucoide, consistente com ABPA. Controlar ABPA pode prevenir e reduzir as crises de angioedema e os danos ao tecido pulmonar. O diagnóstico precoce de ambas as doenças deve ser enfatizado para reduzir a morbimortalidade.

Clinical Profile of Children With Cystic Fibrosis Surviving Through Adolescence and Beyond

Objective: To document morbidities in adolescents with cystic fibrosis (CF) from India. Methods: Details of children with cystic fibrosis surviving beyond 15 years of age were extracted from hospital records, and analyzed. Results: 43 children [Median (IQR) age 18.7 (17, 20.6) years, were enrolled. Median (IQR) body mass index was 15.82 (13.5, 19.05) kg/m2. Pseudomonas species were isolated from respiratory specimens of 34 (79%) adolescents. Allergic bronchopulmonary aspergillosis (ABPA) and Cystic fibrosis-related diabetes (CFRD) were seen in 12 (28%) and 11 (26%) patients, respectively. Conjugated hyperbilirubinemia and distal intestinal obstruction syndrome (DIOS) were diagnosed in 15 (35%) and 6 (14%) children, respectively. Pseudomonas species colonization (P=0.04) and multiple pulmonary exacerbations in last one year (P<0.001) were significant predictors of FEV1% predicted. Conclusion: Malnutrition, chronic airway colonization, ABPA, CFRD, conjugated hyperbilirubinemia and DIOS are morbidities observed in adolescents with CF in India. The data support the need for early screening of CF-associated morbidities.

Case report of allergic bronchopulmonary aspergillosis with hemoptysis in a child with cystic fibrosis / 中华实用儿科临床杂志

The clinical data of a cystic fibrosis (CF) child with allergic bronchopulmonary aspergillosis (ABPA) and hemoptysis in the Department of Respiratory Disease Ⅰ, Beijing Children′s Hospital, Capital Medical University in May 2021 were retrospectively analyzed.Meanwhile, relevant literature was reviewed to analyze the clinical characteristics, diagnosis and treatment of CF patients with ABPA.This patient was a 15 years and 4 months old boy and complained of recurrent cough with sputum.The test showed increased blood eosinophils, total serum IgE higher than 500 IU/mL, positive aspergillus fumigatus specific IgE and IgG antibodies.Chest CT revealed central bronchiectasis and high-density mucus thrombus, and the patient was initially diagnosed with ABPA.Further examinations suggested the sweat chloride concentration was 89 mmol/L, and the genetic results showed a compound heterozygous mutation of CFTR (c.2909G>A from his father, c.3310G>T from his mother). Then, he was diagnosed with CF complicated with ABPA and treated with glucocorticoid and antifungal therapy.The disease was repeated after drug withdrawal.Due to hemoptysis, the right upper lobe lobectomy was performed.Unfortunately, ABPA occurred again 2 years later.The child is being followed up at present.CF is a rare monogenetic disease with poor prognosis.It is difficult to treat CF patients with ABPA and the disease repeats easily.Early identification and treatment will improve the prognosis.

Role of eosinophil extracellular traps in the pathogenesis of chronic airway diseases / 中华微生物学和免疫学杂志

Eosinophil extracellular traps (EETs), an important pathway of eosinophil to exert its effects, are composed of DNA fibers, histone and eosinophil granule proteins. Recently, many researches have shown that EETs play an important role in the genesis and development of respiratory diseases including asthma, allergic bronchopulmonary aspergillosis and chronic obstructive pulmonary disease. EETs can directly damage airway epithelial cells, promote airway inflammation and airway hypersecretion, increase the stickiness of secretions and induce the generation of autoantibody, helping eosinophils and their products participate in a cascade of events leading to inflammation and disease. Researches on EETs can also be helpful in investigating new targets for the treatment of chronic airway diseases.

Conocimientos y tendencias actuales sobre la aspergilosis broncopulmonar alérgica / Current knowledge and trends on allergic bronchopulmonary aspergillosis

Introducción: La aspergilosis broncopulmonar alérgica es una enfermedad pulmonar inflamatoria, caracterizada por una reacción de hipersensibilidad a la colonización de la vía aérea por Aspergillus fumigatus en individuos susceptibles, generalmente pacientes con asma y fibrosis quística. Objetivo: Actualizar los conocimientos en el diagnóstico y manejo de la aspergilosis broncopulmonar alérgica. Desarrollo: Se realizó una revisión bibliográfica temática, observacional y retrospectiva, de diciembre de 2019 a julio de 2020. Se accedió a bases de datos como PubMed/MEDLINE, SciElo, ReserchGate, Scopus, ScienceDirect, Redalyc, Latindex, Wed of Science y LILACS, usando los descriptores en Ciencias de la Salud (Aspergillus fumigatus, aspergilosis broncopulmonar alérgica, hipersensibilidad, allergic bronchopulmonary aspergillosis, aspergilose broncopulmonar alérgica, pulmonary aspergillosis, aspergilose pulmonar, hypersensitivity, hipersensibilidade). Se incluyeron artículos escritos en español, inglés o portugués, que informaron sobre la temática relacionada con aspergilosis broncopulmonar alérgica; seleccionados por la lectura del título, el resumen, el texto completo y por la evaluación de las variables (tipos de diseño metodológico, aspectos metodológicos generales propios de cada uno de los diseños encontrados y calidad de la investigación). Con estos criterios, fueron seleccionados 36 artículos nacionales e internacionales que incluyeron artículos originales, revisiones bibliográficas, estudios de intervención, revistas y anuarios estadísticos. Conclusiones: La aspergilosis broncopulmonar alérgica es mucho más frecuente de lo que se suponía, pero con asiduidad se subdiagnostica y el diagnóstico se hace tardíamente, lo que empeora el pronóstico de estos pacientes. Establecer el diagnóstico y tratamiento oportuno ayudará prevenir el desarrollo de serias complicaciones(AU)

Introduction: Allergic bronchopulmonary aspergillosis is an inflammatory lung disease characterized by a hypersensitivity reaction to colonization of the airway by Aspergillus fumigatus in susceptible individuals, generally patients with asthma and cystic fibrosis. Objective: To update knowledge in the diagnosis and management of allergic bronchopulmonary aspergillosis. Development: A thematic, observational and retrospective bibliographic review was carried out, from December / 2019 to July / 2020. Databases such as PubMed / MEDLINE, SciElo, ReserchGate, Scopus, ScienceDirect, Redalyc, Latindex, Wed of Science and LILACS were accessed, using descriptors in Health Sciences (Aspergillus fumigatus, allergic bronchopulmonary aspergillosis, hypersensitivity, allergic bronchopulmonary aspergillosis, allergic bronchopulmonary aspergillose, pulmonary aspergillosis, pulmonary aspergillus, hypersensitivity, hypersensitivity). Articles written in Spanish, English or Portuguese were included, which reported on the subject related to allergic bronchopulmonary aspergillosis, selected by reading the title, the abstract, the full text and by evaluating the variables (types of methodological design, aspects general methodological characteristics of each of the designs found and the quality of the research). With these criteria, 36 national and international articles were selected that included original articles, bibliographic reviews, intervention studies, journals and statistical yearbooks. Conclusions: Allergic bronchopulmonary aspergillosis is much more frequent than previously assumed, but it is frequently underdiagnosed and the diagnosis is made late, which worsens the prognosis of these patients. Establishing timely diagnosis and treatment will help prevent the development of serious complications(AU)

Prevalencia de aspergilosis broncopulmonar alérgica en niños con fibrosis quística / Prevalence of bronchopulmonary aspergillosis in children with cystic fibrosis

La aspergilosis broncopulmonar alérgica (ABPA) es una reacción de hipersensibilidad secundaria al Aspergillus fumigatus (Af) que complica la evolución en fibrosis quística (FQ). Existen pocos estudios pediátricos de su prevalencia publicados en el mundo y en Chile se desconoce. El objetivo de este trabajo fue estimar la prevalencia de ABPA en niños con FQ en un hospital de referencia, explorar factores de riesgo y describir los criterios diagnósticos, tratamiento y evolución. Se incluyeron retrospectivamente los niños con FQ atendidos en un hospital terciario en Santiago de Chile (Hospital Roberto del Río) entre los años 2011 a 2019, se identificaron aquellos con diagnóstico de ABPA. Se registraron criterios diagnósticos según la Cystic Fibrosis Foundation, presencia de factores de riesgo, tratamientos recibidos y efectos adversos. De 65 pacientes con FQ atendidos en este período, la prevalencia de ABPA fue del 12%. El promedio de edad al diagnóstico fue ± 11 años (5-17 años), predominando la edad adolescente y el género masculino. El 50% cumplieron con los criterios clásicos, el 87,5% usaron antibióticos y el 62,5% corticoides inhalados. La respuesta favorable al tratamiento inicial con corticoides y antifúngico vía oral fue 62,5%, con una exacerbación al momento del estudio. El 25% se comportaron como refractario y el 12,5% respondieron a tratamiento con pulsos de metilprednisolona. El 37,5% presentaron eventos adversos relacionados a corticoides. La prevalencia de ABPA observada es comparable a las series publicadas. Se necesitan trabajos prospectivos para conocer la prevalencia nacional y su tendencia a lo largo de los años, identificando factores de riesgo.

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity response to Aspergillus fumigatus (Af) and worsens outcome in children with cystic fibrosis (CF). Its prevalence varies in the literature, but we do not know it in Chile. The aim of the study was to know the prevalence of ABPA in children with CF and to describe risk factors, diagnostic criteria, treatment and outcome. We included all patients with CF seen in a tertiary hospital in Santiago, Chile (Hospital Roberto del Río), between 2011 and 2019; ABPA cases (CF Foundation diagnostic criteria) were identified for the estimation of the prevalence. Risk factors, diagnostic criteria and treatment were recorded, as proposed by the Cystic Fibrosis Foundation. A total of 65 patients with CF were identified in the study period, with a prevalence of 12% (8 cases). Mean age at diagnosis ± 11 years (5-17), more frequent in adolescence and male. CF Foundation criteria diagnostic were identified in 50% of cases, with high frequency of antibiotic use (87,5%) and inhaled steroids (62,5%). Positive oral steroids and antifungal treatment response was 62,5%. Refractary response was 25% and 12,5% needed intravenous metilprednisolone pulses. A 37,5% of cases presented adverse effects to steroids. Prevalence of ABPA is comparable to literature. A prospective study is needed to identified national prevalence and trends, identifying risks factors.

Long-term prognosis of allergic bronchopulmonary aspergillosis in children with cystic fibrosis / 中华实用儿科临床杂志

Objective:To analyze the long-term prognosis and prognostic factors of allergic bronchopulmonary aspergillosis(ABPA) in children suffering from cystic fibrosis (CF).Methods:An observational study was performed.All children who were admitted to the Department of Respiratory, Beijing Children′s Hospital, Capital Medical University from August 2014 to June 2018, with more than 2 years of followed up for the diagnosis of CF accompanied by ABPA were involved.Results:Three children met the inclusion criteria, with 2 boys and 1 girl, and their diagnostic age were 14, 8 and 9 years old, respectively.The follow-up duration ranged from 2 to 6 years.All the 3 cases were treated with systemic corticosteroids and antifungal agent.In case 1, the initial dose of prednisone was 0.75 mg/(kg·d), and the course of treatment was more than 5 years.The corticosteroid-dependent patient suffered from expectoration and chest pain, and radiographic findings indicated exacerbation, while his lung function was normal.Treating with initial dose of prednisone 2 mg/(kg·d) for 9 months, case 2 had normal serum immunoglobulin E(IgE) concentration, but his pulmonary artery was infiltrated by lesions, thus leasing to lobectomy.In case 3, the initial dose of prednisone was 0.6 mg/(kg·d), and the course of treatment was 18 months.And she developed persistent hypoxemia, and decreased pulmonary function, so lung transplantation was necessary 2 years after diagnosis.Conclusions:Systemic glucocorticoid combined with antifungal therapy is the main treatment for CF with ABPA, but there are individual differences in the efficacy.The level of serum total IgE is not always consistent with lung function and chest images.The overall prognosis is poor, and it is infeasible to evaluate the prognosis by single factor.

Asma crítica asociada a aspergilosis broncopulmonar alérgica: reporte de un caso

RESUMEN El síndrome de asma crítica es la peor consecuencia de una exacerbación aguda de asma. La aspergilosis broncopulmonar alérgica es una de las patologías más frecuentes que se mimetizan con este síndrome y está asociada a un alto riesgo de mortalidad cuando no se realiza el diagnóstico oportuno en pacientes asmáticos de difícil control. Presentamos el caso de un varón de 15 años que ingresó a la unidad de cuidados intensivos con clínica de asma crítica, donde se hizo un diagnóstico de aspergilosis broncopulmonar alérgica y respondió favorablemente con voriconazol y corticoides. En nuestro medio se debe considerar el diagnóstico de aspergilosis broncopulmonar alérgica en todo paciente con clínica de asma crítica o con una enfermedad pulmonar crónica de difícil control; el diagnóstico y el tratamiento oportunos mejoran la calidad de vida y el pronóstico de los pacientes.

ABSTRACT Critical asthma syndrome is the most severe consequence of an acute asthma exacerbation. Allergic bronchopulmonary aspergillosis is one of the most frequent pathologies that mimic critical asthma syndrome and is associated with a high mortality risk when timely diagnosis is not achieved in difficult-to-control asthmatic patients. We present the case of a 15-year-old male who was admitted to the intensive care unit with critical asthma signs and symptoms, where a diagnosis of allergic bronchopulmonary aspergillosis was made. He responded favorably with voriconazole and corticoids. In our context, the diagnosis of allergic bronchopulmonary aspergillosis should be considered in all patients with critical asthma or with a chronic lung disease that is difficult to control. Early diagnosis and treatment improve the quality of life and prognosis of patients.

Case analysis based on 2017 version of Expert Consensus on the Diagnosis and Treatment of Allergic Bronchopulmonary Aspergillosis / 上海交通大学学报（医学版）

Objective: To analyze the cases of ABPA based on 2017 version of Expert Consensus on the Diagnosis and Treatment of Allergic Bronchopulmonary Aspergillosis (ABPA) (Expert Consensus in short) developed by Asthma Group of Chinese Medical Association Respiratory Diseases Society. Methods: According to the Expert Consensus, the clinical data of 12 patients with ABPA admitted to Ruijin Hospital, Shanghai Jiao Tong University School of Medicine from January 2013 to December 2017 were retrospectively analyzed. Results: Among the 12 patients with ABPA, 6 were males and 6 were females. The clinical manifestations were cough, having phlegm, short of breath, etc. The total immunoglobulin E (tIgE) in sera of 10 cases increased, and the peripheral blood eosinophils of 9 cases increased. Seven cases underwent the skin test, 3 of whom were positive in aspergillus. Serum aspergillus-specific IgE (sIgE) of all the 5 cases tested was elevated. The most patients showed bronchiectasis in chest CT, and some also with mucus plug. Fifty percent of the cases fully met the diagnostic criteria of Expert Consensus. All the patients were treated with corticosteroid, and 9 of them were also treated with antifungal drugs. Conclusion: The clinical manifestations of ABPA are atypical. For the patients with lung diseases such as asthma and bronchiectasis, serum tIgE, aspergillus sIgE and eosinophil levels need to be monitored. Aspergillus skin test and imaging examination are helpful to the diagnosis of ABPA. The main treatment is the combination of corticosteroid and antifungal drugs.

Exames para avaliar a sensibilização ao aspergillus fumigatus em fibrose cística / Tests to assess sensitization to aspergillus fumigatus in cystic fibrosis

RESUMO Objetivo: Avaliar os resultados dos exames utilizados para identificar a sensibilização IgE-mediada ao Aspergillus fumigatus em pacientes com fibrose cística. Métodos: Estudo transversal descritivo com amostra de conveniência de 86 pacientes com fibrose cística, acompanhados em Serviço de Referência de Fibrose Cística de hospital universitário terciário. Realizaram-se exames para avaliar sensibilização ao A. fumigatus em pacientes com fibrose cística: IgE sérica total, contagem de eosinófilos sanguíneos, identificação do fungo por swab de orofaringe ou por cultura de escarro, IgE sérica específica e testes cutâneos de hipersensibilidade imediata. Foram comparados os resultados dos diferentes exames realizados. Resultados: Em 33 (38,4%) pacientes com fibrose cística, com faixa etária de 1 a 33 anos (mediana de 8 anos), os resultados dos exames sobre sensibilização IgE mediada ao A. fumigatus foram: em 16 pacientes, aumento de IgE sérica específica (>0,35 kU/L); em 23, positividade aos testes cutâneos; e seis mostraram sensibilização a partir dos dois exames. Foram observados dois pacientes com eosinofilia (>1.000 eosinófilos/mm3) e sete com aumento de IgE sérica total (>1.000 UI/mL), sem que esses apresentassem positividade aos testes cutâneos ou aumento de IgE específica ao A. fumigatus. Em nenhum paciente foi isolado A. fumigatus no swab de orofaringe e/ou na cultura de escarro. Conclusões: Concluímos que, entre os exames para avaliar a sensibilização ao A. fumigatus na fibrose cística, são necessários os teste cutâneos de hipersensibilidade imediata e a dosagem de IgE sérica específica ao A. fumigatus. A eosinofilia sérica e a cultura de secreções respiratórias não foram essenciais neste estudo.

ABSTRACT Objective: To evaluate the results of the tests used to identify the IgE mediated sensitization to Aspergillus fumigatus in patients with cystic fibrosis. Methods: This is a cross-sectional descriptive study with a convenience sample of 86 patients diagnosed with cystic fibrosis in the Reference Service in Cystic Fibrosis at a tertiary teaching hospital. The following tests were performed to assess the sensitization to A. fumigatus in patients with cystic fibrosis: Total serum IgE, eosinophil count, fungus detection through oropharyngeal swab or sputum culture, serum-specific IgE, and immediate-type hypersensitivity (IgE) skin tests. We compared the results of the different tests performed. Results: In 33 (38.4%) patients with cystic fibrosis, with ages ranging from 1 to 33 years (median of 8 years), the IgE-mediated A. fumigatus sensitization test results were: in 16 patients, there was an increase in serum-specific IgE (>0.35 kU/L); in 23, skin tests were positive; and six had sensitization in both tests. We observed two patients with eosinophilia (>1,000 eosinophils/mm3) and seven with increasing total serum IgE (>1,000 IU/mL), all of whom obtained negative results in skin tests and had no IgE increase specific to A. fumigatus. A. fumigatus was not detected in oropharyngeal swabs and/or sputum culture of any patients. Conclusions: We conclude that, among the tests used to assess sensitization to A. fumigatus in cystic fibrosis patients, both serum-specific IgE and immediate-type hypersensitivity (IgE) skin tests are required. Serum eosinophilia and respiratory secretion culture were not essential in this study.

Pharmaceutical Care for a Patient with AECOPD Complicated with Allergic Bronchopulmonary Aspergil-losis / 中国药房

OBJECTIVE:To explore the role of clinical pharmacists in the therapy for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated with allergic bronchopulmonary aspergillosis (ABPA). METHODS:Clinical pharmacists participated in the therapy for a AECOPD patient with ABPA. According to patient's con-dition,clinical pharmacists suggested adjusting the inhalation order of salbutamol and budesonide aerosol inhalation;stop-ping cefatriaxone and adjusting to intravenous injection of voriconazole;and then adjusting voriconazole to oral dosage form timely,monitoring therapy duration. Clinical pharmacists paid close attention to therapeutic efficacy and ADR,and provided medication education for patients. RESULTS:Physicians adopted the suggestion of clinical pharmacists to adjust inhalation order of aerosols,the dosage and route of administration of voriconazole. The patient's condition was improved obviously,and the drug therapy was continued after discharge. CONCLUSIONS:Clinical pharmacists participating in the whole process of treatment improves therapeutic efficacy,reduces the occurrence of ADR and promotes rational drug use in clinic.

Childhood allergic bronchopulmonary aspergillosis presenting as a middle lobe syndrome

Allergic bronchopulmonary aspergillosis (ABPA) is infrequently documented in children with asthma. Although collapse is not uncommon, middle lobe syndrome (MLS) as a presentation of ABPA is rather a rarity. A 9-year-old female child with asthma presented with increase in intensity of symptoms along with a right midzone patchy consolidation on a chest radiograph. In addition, an ill-defined opacity abutting the right cardiac border with loss of cardiac silhouette was noted. A right lateral view confirmed a MLS, which was further corroborated by high resolution computed tomography. Central bronchiectasis was also observed, which prompted a work-up for ABPA. The child met 7/8 major diagnostic criteria for ABPA. She was then initiated on oral prednisolone that resulted in a marked clinical improvement within a fortnight. Radiological clearance occurred at 3 months with inflation of the middle lobe. ABPA presenting with MLS in a child is yet to be reported. A high index of suspicion is required to establish the diagnosis of ABPA in a child presenting with MLS. This would obviate the invasive investigations usually done to ascertain the cause of MLS.

Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity

In susceptible individuals, inhalation of Aspergillus spores can affect the respiratory tract in many ways. These spores get trapped in the viscid sputum of asthmatic subjects which triggers a cascade of inflammatory reactions that can result in Aspergillus-induced asthma, allergic bronchopulmonary aspergillosis (ABPA), and allergic Aspergillus sinusitis (AAS). An immunologically mediated disease, ABPA, occurs predominantly in patients with asthma and cystic fibrosis (CF). A set of criteria, which is still evolving, is required for diagnosis. Imaging plays a compelling role in the diagnosis and monitoring of the disease. Demonstration of central bronchiectasis with normal tapering bronchi is still considered pathognomonic in patients without CF. Elevated serum IgE levels and Aspergillus-specific IgE and/or IgG are also vital for the diagnosis. Mucoid impaction occurring in the paranasal sinuses results in AAS, which also requires a set of diagnostic criteria. Demonstration of fungal elements in sinus material is the hallmark of AAS. In spite of similar histopathologic features, co-existence of ABPA and AAS is still uncommon. Oral corticosteroids continue to be the mainstay of management of allergic aspergillosis. Antifungal agents play an adjunctive role in ABPA as they help reduce the fungal load. Saprophytic colonization in cavitary ABPA may lead to aspergilloma formation, which could increase the severity of the disease. The presence of ABPA, AAS, and aspergilloma in the same patient has also been documented. All patients with Aspergillus-sensitized asthma must be screened for ABPA, and AAS should always be looked for.

Allergic Bronchopulmonary Aspergillosis: An Occult Disease Waiting To Be Explored- Case Report And Review Of Literature.

Allergic bronchopulmonary aspergillosis (ABPA) is a slowly progressive disease caused by hypersensitivity to Aspergillus fumigatus. This condition is most commonly seen in patients with asthma and cystic fibrosis. ABPA mimics a wide range of diseases, thereby further accentuating the difficulties faced by medical practitioners in diagnosing this condition. Even today, this condition remains under diagnosed in many countries with reports of mean diagnostic latency of ten years between the occurrence of symptoms and the diagnosis. We present a case report and review of literature with the aim of highlighting the complicated nature of this enigmatic illness.

Non-Cystic Fibrosis Bronchiectasis in Children: Clinical Profile, Etiology and Outcome.

Objective: To describe clinical profile, etiology and outcome in children with non-cystic fibrosis bronchiectasis. Methods: A chart review of children diagnosed with non-cystic fibrosis bronchiectasis, attending pediatric chest clinic of tertiary care hospital. Results: The underlying cause was identified in 51 (63.8%) out of 80 children (mean age, 9.6 y). Common causes were post-infectious in 19 (23.8%), suspected primary ciliary dyskinesia in 12 (15%), and allergic bronchopulmonary aspergillosis in 6 (7.5%). One or more complications were observed in 76 (95%) patients; 14 (17.5%) children required surgery and 5 (11.1%) children died. Conclusions: Common causes of non-cystic fibrosis bronchiectasis are post infectious and primary ciliary dyskinesia. There is a need to create awareness about early diagnosis of bronchiectasis as it is often delayed.

Delayed Diagnosis of Small Cell Lung Cancer in a Patient with Allergic Bronchopulmonary Aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disorder induced by Aspergillus fumigatus that occurs generally in patients with underlying chronic airway disorders. However, the development of ABPA associated with lung malignancy remains unknown. An 80-year-old woman was admitted for evaluation of chronic cough. Her radiologic finding was a mass like opacity with mucoid impaction, showing finger-in-glove sign, one of the typical radiologic findings for ABPA. In addition, laboratory tests revealed that her data satisfied the diagnostic criteria for ABPA. Interestingly, final pathologic examination showed that the mass lesion was small cell lung cancer. Here, we describe a case of delayed diagnosis of small cell lung cancer with ABPA, suggesting that a possibility of accompanying lung malignancy such as small cell lung cancer should be considered in patients with ABPA. This case let us realize the importance of clinical suspicion that different entities of diseases can be occurred simultaneously for the correct diagnosis without delay.

Analysis of allergic bronchopulmonary aspergillosis in 8 children / 中华实用儿科临床杂志

Objective To summarize the clinical features of the allergic bronchopulmonary aspergillosis (ABPA) in children,in order to improve the understanding for ABPA and make early diagnosis and treatment of the disease.Methods A retrospective study was performed on ABPA patients diagnosed in Department of Respiratory Medicine,Beijing Children's Hospital Affiliated to Capital Medical University from March 2010 to December 2013.The clinical features,laboratory results,image characteristics and the prognosis information were reviewed.Results Eight ABPA cases met the diagnostic criterion.All patients were school-age children (7 years and 2 months to 13 years and 8 months old).Cough (8 cases),productive sputum (8 cases),wheezing (5 cases),fever (4 cases) and hemoptysis (3 cases) were the main clinical features.Six of the 8 patients showed eosinophilia.IgE level was elevated in 7 patients (1.000-5.000 IU/L).All 8 patients were allergic to aspergillus fumigatus,while only 2 cases were positive in sputum culture for aspergillus fumigatus.CT scans showed pulmonary opacities in all 8 cases,while 7 patients had typical central bronchiectasis.Seven patients were treated with the regimen,which included glucocorticosteroid,antifungal agents (voriconazole or itraconazole) and regular bronchoscope.The symptoms of all treated patients relieved,the total serum IgE level and eosinophil cell count decreased spontaneously after the therapy.Conclusions ABPA is rare in children and the clinical features are non-specific.If the patient has elevated total IgE level in serum and eosinophilia,especially in patients with underling diseases,ABPA should be suspected.The positive result of specific antibodies to aspergillus fumigatus and central bronchiectasis on the radiology may give the suggestive diagnosis.ABPA patients generally have good response to the therapy of glucocorticosteroid and antifungal agents.

A Case of Allergic Bronchopulmonary Aspergillosis Forming Broncholith Misdiagnosed as an Uncontrolled Asthma with Broncholithiasis

A 55-year-old woman was referred to the division of pulmonology at Severance Hospital for the investigation of uncontrolled asthma with recurrent cough at night, blood-tinged sputum, malaise, and wheezing since 3 months. Chest computed tomography revealed bronchiectasis and broncholithiasis in the lateral segmental bronchus of the right middle lobe and the anterobasal segmental bronchus of the right lower lobe. Bronchoscopic broncholith removal was performed because of recurrent blood-tinged sputum and the outflow of purulent exudate behind the broncholith in the lateral segmental bronchus of the right middle lobe. The extracted material presenting amorphous eosinophilic necrotic materials with calcification was compatible with broncholithiasis. Following decalcification, histopathology revealed degenerated septate fungal hyphae and spores that were morphologically consistent with Aspergillus spp. A final diagnosis was allergic bronchopulmonary aspergillosis (ABPA) forming broncholith. The results from this case suggest that the early recognition of ABPA should be considered in patients with uncontrolled asthma accompanied by broncholithiasis.