Description
Allergic Bronchopulmonary Aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus fumigatus seen in patients with asthma or cystic fibrosis. Diagnosis involves clinical suspicion with symptoms like cough, wheezing, and mucus plugs, along with elevated total IgE (>1000 IU/mL), positive Aspergillus-specific IgE/IgG, eosinophilia, and characteristic findings on HRCT chest (central bronchiectasis, mucus impaction). Management focuses on controlling inflammation and fungal burden using oral corticosteroids as first-line therapy, with antifungal agents like itraconazole or voriconazole to reduce fungal load and steroid dependence. Regular monitoring of IgE levels helps assess response and detect relapses early.
Summary Listen
- Aspergillus fumigatus is the most common cause of Allergic Bronchopulmonary Aspergillosis (ABPA), a hypersensitivity reaction primarily affecting asthmatic patients. It's an airborne fungus found in soil, compost, and water-damaged areas, with spores that can trigger allergic reactions in the airways. While traditionally associated with warmer climates, it's expanding into cooler regions, potentially increasing the number of affected individuals.
- ABPA is a complex immunological response to Aspergillus, involving TH2-mediated immune reactions and type 1 and 3 hypersensitivity. Symptoms are uncontrolled asthma, despite optimal treatment, and recurrent exacerbations. Delayed diagnosis can lead to repeated hospitalizations, increased symptom burden, and bronchiectasis. Studies suggest that 16-20% of asthmatics in India may have ABPA.
- Diagnosis involves evaluating patients with uncontrolled asthma for elevated Aspergillus-specific IgE, total IgE (above 500), and eosinophil counts. CT scans can reveal bronchiectasis, mucus plugging, or high-attenuation mucus. The Dell C consensus criteria provides a structured approach. ABPM (allergic bronchopulmonary mycosis) should be suspected if the patient has ABPA-like symptoms but negative Aspergillus fumigatus-specific IgE.
- Treatment principles involve anti-inflammatory drugs (steroids) and antifungal medications (itraconazole) to alleviate symptoms, improve asthma control, prevent exacerbations, and prevent lung progression. Oral steroids are the first line. A 4-month course of prednisone is generally recommended.
- The case study presented highlighted a patient with recurrent ABPA exacerbations despite previous treatment with steroids and itraconazole. Biological therapy (omalizumab) led to rapid and significant improvements in symptoms, lung function, and radiological findings after steroid and anti-fungal therapies have been attempted. However, even with marked improvement, the patient had not yet achieved complete remission, necessitating continued biological treatment.
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About the Speakers
Dr. Nishant Sinha
Senior Consultant Pulmonologist Associate Director AIG Hospitals, Hyderabad
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