Allergic Bronchopulmonary Aspergillosis (Allergic Aspergilloses Bronchopulmonary)

Allergic bronchopulmonary aspergillosis is a disease characterized by a hypersensitivity reaction to aspergillus fumigatus after its repeated inhalation and is most frequently encountered in patients suffering from asthma or cystic fibrosis (CF). The diagnosis is based on clinical, radiographic and microbiological criteria, but symptoms may not be apparent until advanced stages of the disease occur.

The disease is related to the following process: infectious.

Presentation

Allergic bronchopulmonary aspergillosis (ABPA) is one of the main forms of pulmonary disease caused by aspergillus fumigatus, perhaps the most important fungal pathogen in clinical practice, together with candida albicans [1] [2] [3]. It is primarily diagnosed in children and younger adults [4], and signs and symptoms stem from a hypersensitivity reaction induced by repeated inhalation of A. fumigatus conidia, after which both innate and adaptive immune mechanisms initiate an inflammatory reaction [1] [4] [5]. ABPA is diagnosed in up to 6% of patients suffering from chronic asthma and in almost 15% of individuals harboring a diagnosis of cystic fibrosis, suggesting that these two conditions are most important risk factors [5] [6]. In the majority of cases, clinical deterioration of preexisting pulmonary disease is the principal manifestation, with symptoms such as more pronounced cough, wheezing, increased sputum production, hemoptysis, dyspnea, chest pain and the appearance of exercise-induced asthma [2] [6]. Recurrent fever can also be reported [6]. In more severe cases, cyanosis, digital clubbing, and cor pulmonale can be present. However, patients often show minimal signs of the disease for a prolonged period of time, especially if neither asthma nor CF is present [6]. Moreover, without an adequate diagnosis and early initiation of therapy, the clinical course of ABPA is distinguished by repeated remission and exacerbation of symptoms, eventually leading to pulmonary fibrosis, bronchiectasis and chronic production of sputum [2] [3]. The importance of early recognition lies in the fact that pulmonary fibrosis has a poor long-term outcome and may progress to respiratory failure [2] [5].

Workup

The diagnosis of ABPA is not easy to attain in patients who develop nonspecific lung-related signs and symptoms, especially when pulmonary conditions, such as asthma and CF, are concomitantly present. A detailed patient history and a thorough physical examination (with an emphasis on pulmonary auscultation), however, are detrimental parts of the diagnostic workup, as they can identify recent exacerbation or the appearance of new lung-related symptoms. Moreover, many individuals already have some other allergic disorders (for eg. rhinitis, conjunctivitis, atopic dermatitis, etc.), which may be another clue toward ABPA as a differential diagnosis [4]. Because clinical findings are not specific for the diagnosis of ABPA, its recognition relies on the fulfillment of the following criteria [1] [2] [6] [7] [8]:

  • History of asthma (considered to be one of the main prerequisites).
  • Clinical deterioration of preexisting pulmonary symptoms (if patients suffer from asthma or CF).
  • Immediate hypersensitivity to aspergillus spp. confirmed by a skin prick test.
  • Elevated serum immunoglobulin (Ig) E levels (> 416 IU/mL or > 1000 ng/mL).
  • Presence of IgE or IgG-specific antibodies to aspergillus spp.
  • Peripheral blood eosinophilia confirmed on a complete blood count (CBC).
  • Radiographic signs - Plain radiography, often employed as the initial imaging method, shows pulmonary infiltrates and consolidation (also termed non-homogenous opacities), as well as mucus plugs, lobar or segmental lung collapse and presence of fluid in the bronchi in the initial stages of the disease [4] [6]. Inflammation of the airways, often designated as "tramline" sign, is frequently visible in patients suffering from ABPA, whereas other notable radiographic features are edema of the bronchial wall, "toothpaste" shadows, and mucoid plugs causing "glover finger" opacities [4] [6]. Although plain radiography can be highly useful, high-resolution computed tomography (HRCT) is proven to be a superior method for evaluation of many pulmonary diseases, including ABPA, due to its ability to visualize lesions in more detail [1] [4] [5] [6]. For this reason, HRCT should be used whenever possible in patients with suspected ABPA.

Epidemiology

Sex distribution
Age distribution
Self-assessment

References

  1. Agarwal R, Chakrabarti A, Shah A, et al. Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria. Clin Exp Allergy. 2013;43(8):850-873.
  2. Greenberger PA, Bush RK, Demain JG, Luong A, Slavin RG, Knutsen AP. Allergic Bronchopulmonary Aspergillosis. J Allergy Clin Immunol Pract. 2014;2(6):703-708.
  3. Mandell GL, Bennett JE, Dolin R. Mandel, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, Pennsylvania: Churchill Livingstone; 2015.
  4. Tillie-Leblond I, Tonnel AB. Allergic bronchopulmonary aspergillosis. Allergy. 2005;60(8):1004-1013.
  5. Knutsen AP, Slavin RG. Allergic Bronchopulmonary Aspergillosis in Asthma and Cystic Fibrosis. Clin Dev Immunol. 2011;2011:843763.
  6. Shah A, Panjabi C. Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity. Allergy Asthma Immunol Res. 2016;8(4):282-297.
  7. Agarwal R, Gupta D, Aggarwal AN, et al. Clinical significance of decline in serum IgE levels in allergic bronchopulmonary aspergillosis. Respir Med. 2010;104(2):204-210.
  8. Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology. Seventh edition. Philadelphia: Elsevier/Saunders; 2013.

  • A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis - DA Stevens, HJ Schwartz, JY Lee - England Journal of , 2000 - Mass Medical Soc
  • Allergic bronchopulmonary aspergillosis - RG Slavin, CC Gottlieb, LV Avioli - Archives of internal medicine, 1986 - Am Med Assoc
  • A review of non-cystic fibrosis pediatric bronchiectasis - EJ Boren, SS Teuber, ME Gershwin - Clinical Reviews in Allergy and , 2008 - Springer
  • In the collagen region of SP-A2 with increased levels of total IgE antibodies and eosinophilia in patients with allergic bronchopulmonary aspergillosis - S Saxena, T Madan, A Shah, K Muralidhar - Journal of allergy and , 2003 - Elsevier
  • A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis - DA Stevens, HJ Schwartz, JY Lee - England Journal of , 2000 - Mass Medical Soc
  • A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis - DA Stevens, HJ Schwartz, JY Lee - England Journal of , 2000 - Mass Medical Soc
  • Allergic bronchopulmonary aspergillosis in patients with cystic fibrosis - AP Knutsen, RG Slavin - Clinical Reviews in Allergy and Immunology, 1991 - Springer
  • A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis - DA Stevens, HJ Schwartz, JY Lee - England Journal of , 2000 - Mass Medical Soc
  • Allergic bronchopulmonary aspergillosis - BA Cockrill, MD, CA Hales, MD - Annual review of medicine, 1999 - annualreviews.org
  • Adjunctive therapy of allergic bronchopulmonary aspergillosis with itraconazole. - DW Denning, JE Van Wye, NJ Lewiston - , 1991 - chestjournal.chestpubs.org
  • Allergic bronchopulmonary aspergillosis - I Tillie‐Leblond, AB Tonnel - Allergy, 2005 - Wiley Online Library
  • A practical workup for eosinophilia - ML Brigden - Postgraduate medicine, 1999 - postgradmed.org
  • A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis - DA Stevens, HJ Schwartz, JY Lee - England Journal of , 2000 - Mass Medical Soc
  • A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis - DA Stevens, HJ Schwartz, JY Lee - England Journal of , 2000 - Mass Medical Soc
  • In the collagen region of SP-A2 with increased levels of total IgE antibodies and eosinophilia in patients with allergic bronchopulmonary aspergillosis - S Saxena, T Madan, A Shah, K Muralidhar - Journal of allergy and , 2003 - Elsevier
  • Fumigatus allergens in A fumigatus–sensitized asthmatic subjects allows diagnostic separation of allergic bronchopulmonary aspergillosis from fungal - S Hemmann, G Menz, C Ismail, K Blaser - Journal of allergy and , 1999 - Elsevier
  • Adjunctive therapy of allergic bronchopulmonary aspergillosis with itraconazole. - DW Denning, JE Van Wye, NJ Lewiston - , 1991 - chestjournal.chestpubs.org
  • Allergic bronchopulmonary aspergillosis - PA Greenberger - Journal of Allergy and Clinical Immunology, 2002 - Elsevier
  • Allergic bronchopulmonary aspergillosis in cystic fibrosis—state of the art: Cystic Fibrosis Foundation Consensus Conference - DA Stevens, RB Moss, VP Kurup - Clinical Infectious , 2003 - cid.oxfordjournals.org
  • A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis - DA Stevens, HJ Schwartz, JY Lee - England Journal of , 2000 - Mass Medical Soc
  • Adjunctive therapy of allergic bronchopulmonary aspergillosis with itraconazole. - DW Denning, JE Van Wye, NJ Lewiston - , 1991 - chestjournal.chestpubs.org
  • A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis - DA Stevens, HJ Schwartz, JY Lee - England Journal of , 2000 - Mass Medical Soc
  • Adjunctive therapy of allergic bronchopulmonary aspergillosis with itraconazole. - DW Denning, JE Van Wye, NJ Lewiston - , 1991 - chestjournal.chestpubs.org
  • Allergic bronchopulmonary aspergillosis with low serum immunoglobulin E - RH Schwartz, GE Hollick - Journal of Allergy and Clinical Immunology, 1981 - Elsevier
  • Adjunctive therapy of allergic bronchopulmonary aspergillosis with itraconazole. - DW Denning, JE Van Wye, NJ Lewiston - , 1991 - chestjournal.chestpubs.org
Self-assessment