Allergic bronchopulmonary aspergillosis' diagnosis remains a challenge

INTRODUCTION: Allergic bronchopulmonary aspergillosis (ABPA) is a complex disease, triggered by a hypersensitivity reaction to the allergens of Aspergillus fumigatus, a fungus that opportunistically colonizes the lungs of patients with asthma. The diagnosis of ABPA is difficult. A major problem is the lack of standardized allergens used in the determination of specific IgE, but the use of recombinant allergens has been proposed to overcome this. The aim of the present study is to evaluate whether serological tests for IgE specific to recombinant allergens of A. fumigatus (rAsp) can aid in the detection of sensitization to this fungus and in the diagnosis of ABPA. METHODS: This was an observational, cross-sectional study. The diagnosis of ABPA, using classical criteria, was searched in 65 asthmatics patients with immediate cutaneous reactivity to A. fumigatus. After that, serum titers of IgE against rAsp f 1, rAsp f 2, rAsp f 3, rAsp f 4 and rAsp f 6 were determined. In order to compare the differences between patients with confirmed and excluded diagnosis of ABPA, the two-tailed Fisher's exact test was used. RESULTS: Although 19 of 65 patients had IgE against at least one recombinant, the disease was diagnosed in only six patients by classical criteria. One of them had IgE against all recombinant allergens tested and another one had antibody against Asp f 3. DISCUSSION: The determination of serum IgE against recombinant A. fumigatus allergens in this group was not helpful to make the diagnosis of ABPA, neither to detect sensitization to fungus.     

变应性支气管肺曲霉病血清学诊断的研究进展

变应性支气管肺曲霉病(allergic bronchopulmonary Aspergillosis,ABPA)在囊性纤维化或哮喘患者中是一种常见的临床综合征,可导致不可逆的支气管扩张、肺纤维化,甚至死亡.ABPA的早期诊断及治疗可预防不可逆的肺部损伤.尽管多个APBA的诊断标准被先后提出,然而其临床和影像学特点与囊性纤维化、哮喘曲霉过敏有部分重叠,所以诊断上仍存在一定困难.因此,有效的血清标志物对于ABPA的诊断非常关键.从众所周知的标志物如总血清免疫球蛋白E(immunoglobulin E,IgE)、烟曲霉特异性IgE、烟曲霉特异性免疫球蛋白G(immunoglobulin G, IgG)、沉淀素到新的血清生物标志物如曲霉菌抗原重组体(recombinant Aspergillus fumigatus allergen,rAsp)、胸腺活性调节趋化因子(thymus gland activity regulating chemokine,TARC)、嗜碱细胞活性试验(basophilic cells activity test,BAT)、细胞过敏原刺激实验(cell allergen stimulation test,CAST),结合文献复习上述血清标志物在提高APBA早期发现及诊断中的地位及有效性.     

Intracutaneous tests with recombinant allergens in cystic fibrosis patients with allergic bronchopulmonary aspergillosis and Aspergillus allergy

Allergic bronchopulmonary aspergillosis (ABPA), an intensive inflammatory reaction to Aspergillus fumigatus, can cause irreversible lung damage in patients with cystic fibrosis (CF). The aim of this study was to assess if intracutaneous testing with recombinant A. fumigatus allergens (rAsp f ) allowed a reliable diagnosis of ABPA. Fifty patients with CF were tested, 12 suffering from ABPA, 21 with allergy to A. fumigatus, and 17 CF control patients not sensitized to A. fumigatus. All patients with ABPA reacted to at least one of the two intracellular A. fumigatus allergens rAsp f 4, a 30-kD protein of unknown biologic function, and rAsp f 6, a 23-kD manganese superoxide dismutase, at a concentration of 10(-2) microg/ml. The intracutaneous tests were negative or only marginally positive in the patients with allergy to A. fumigatus and completely negative in the CF control patients. The differential responses to the recombinant A. fumigatus allergens were in perfect agreement with our previous serologic results, so that rAsp f 4 and rAsp f 6 can be considered specific markers for ABPA. Early diagnosis of the disease might help to prevent irreversible lung damage and minimize possible steroid-mediated side effects as a consequence of an optimized control of the disease.     

Chemokines indicate allergic bronchopulmonary aspergillosis in patients with cystic fibrosis

RATIONALE: Allergic bronchopulmonary aspergillosis (ABPA) is characterized by a Th2 immune response. Mouse models suggest a critical role for the Th2 chemokines thymus- and activation-regulated chemokine (TARC) and macrophage-derived chemokine (MDC) in ABPA. OBJECTIVES: To determine whether serum levels of TARC and MDC characterize ABPA in patients with cystic fibrosis (CF) and to examine longitudinally if levels of TARC and MDC indicate ABPA exacerbations in patients with CF. METHODS: Levels of TARC and MDC and levels of Th1 (IL-12 and IFN-gamma) and Th2 (IL-4, IL-5, and IL-13) cytokines were analyzed in serum of 16 patients with CF with ABPA, six non-CF patients with asthma with ABPA, 13 patients with CF colonized with Aspergillus fumigatus, six patients with CF sensitized to A. fumigatus, 12 atopic patients with CF, and 13 non-CF atopic control subjects by ELISA. The longitudinal course of TARC, MDC, and IgE levels was assessed during ABPA episodes. RESULTS: Patients with ABPA had significantly higher serum levels of TARC compared with the other patient groups. Cytokine levels did not differ among the patient groups. Longitudinally, levels of TARC indicated ABPA exacerbations in patients with CF more clearly than IgE levels. In patients with CF and ABPA, levels of TARC correlated positively with specific IgE to A. fumigatus and rAsp f4. CONCLUSIONS: Serum levels of TARC differentiate patients with CF or patients with asthma with ABPA from patients with CF colonized with or sensitized to A. fumigatus, atopic patients with CF, and atopic control subjects. Longitudinally, levels of TARC indicate ABPA exacerbations, suggesting TARC as a marker for identification and monitoring of ABPA in patients with CF.     

A case of effective readministration of itraconazole for recurrent allergic bronchopulmonary aspergillosis]

A 67-year-old woman suffered from productive cough but not from bronchial asthma. Her peripheral blood showed eosinophilia, a high serum level of total immunoglobulin E (IgE), and elevated specific IgE and positive precipitating antibody against Aspergillus fumigatus. Her chest radiograph and computed tomography revealed infiltrative shadows but not central bronchiectasis. Fibreoptic bronchoscopy detected some mucous plugs which grew Aspergillus fumigatus on culture. We therefore made a diagnosis of allergic bronchopulmonary aspergillosis (ABPA). We treated her using only itraconazole. Her respiratory symptoms, eosinophilia, serum IgE level, and pulmonary infiltration gradually improved, but withdrawal of itraconazole exacerbated her respiratory symptom and laboratory data. Administration of itraconazole again resulted in improvement of her symptoms and laboratory data. We report a case of ABPA without bronchial asthma or central bronchiectasis and refer to our diagnostic rationale. Furthermore, we discuss the decrease of allergens by the eradication of Aspergillus fumigatus in the airway with itraconazole to reduce the allergic reaction and improve the clinical symptoms.     

Antigen specific quantification of sulfidoleukotrienes in patients allergic to Betalactam antibiotics.

BACKGROUND: After in vitro allergen-specific stimulation, basophils become activated and release sulfidoleukotrienes LTC4, LTD4 and LTE4. This can be detected by means of the CAST assay. We assessed the positivity criteria and the reliability of antigen-specific sulfidoleukotriene production (CAST) in the in vitro diagnosis of betalactam (BL) allergic patients. MATERIAL AND METHODS: We studied a sample of 67 patients (age 48.94 +/- 15.76 years) who had presented with anaphylaxis or urticaria-angioedema within the first 60 minutes after administration of Amoxicillin (54/67), Penicillin G (7/67), Cefuroxime (5/67) or Cefazoline (1/67). All of them had a positive skin test to at least one of the antigenic determinants of Penicillin. As control group 30 adults with negative skin tests who tolerated BL were included. All of them underwent skin tests, oral provocation tests, specific IgE (CAP-FEIA, Pharmacia) and CAST. RESULTS: Positivity criteria were established by means of ROC curves: a sLT release induced by Betalactams of at least 100 pg/ml and greater than or equal to 3 times the basal value. The overall sensitivity of CAST is 47.7% and specificity 83.3%. Sensitivity of specific IgE is 37.8% and specificity 83.3%. CONCLUSIONS: We have established validated positivity criteria for the CAST technique in patients allergic to Betalactams. This technique is a useful in vitro diagnostic method in patients with IgE-mediated allergy to Betalactam antibiotics.     

Sensitization to Aspergillus antigens and occurrence of allergic bronchopulmonary aspergillosis in patients with asthma

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA), which is predominantly a disease of asthmatic subjects, is caused by hypersensitivity to Aspergillus antigens. Screening for Aspergillus sensitization in asthmatic subjects could identify those who are at risk for ABPA. Few studies have shown that fungal sensitization could be an important risk factor for asthma severity. We sought to determine the frequency of sensitization to Aspergillus antigens in asthmatic subjects and its effect on disease severity. We also determined the occurrence of ABPA in these subjects. DESIGN: Prospective study of consecutive patients with asthma. SETTING: Tertiary university referral hospital, outpatient department. PATIENTS AND METHODS: One hundred five asthmatic subjects and 26 volunteers underwent skin testing with aeroallergens, including Aspergillus, serum precipitins against Aspergillus antigens, and specific IgG against Aspergillus fumigatus, total serum IgE levels, and routine blood and radiologic investigations. ABPA was diagnosed when all eight major criteria were fulfilled. RESULTS: Thirty patients (28.5%) had a positive skin reactivity to Aspergillus antigens. Eleven patients (10.4%) had positive specific reactions to IgG, and 8 patients (7.6%) demonstrated positive reactions to serum precipitins. Eight of these 30 patients (26.6%) received diagnoses of ABPA, which was 7.6% of the total. None of the control subjects were sensitized to Aspergillus antigens. The patients were classified into the following four groups: negative skin test results; positive reactions to aeroallergens other than Aspergillus; positive reactions to aeroallergens including Aspergillus antigens; and patients with ABPA. Based on clinical and serologic parameters, patients with Aspergillus-sensitive asthma and ABPA had a significantly more severe form of the disease. CONCLUSIONS: Sensitization to the mold Aspergillus increases the severity of asthma. ABPA should be excluded in all patients with Aspergillus-sensitive asthma.     

Mild,moderate, and severe forms of allergic bronchopulmonary aspergillosis: a clinical and serologic evaluation

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disorder induced by Aspergillus species colonizing the bronchial tree. There are patients with asthma who fulfill the diagnostic criteria of ABPA by serologic evaluation (specific IgE/IgG to Aspergillus fumigatus), bronchography, CT, and or conventional linear tomography. OBJECTIVE: To identify different forms of ABPA based on various diagnostic criteria. METHODS: Eighteen patients with asthma fulfilling the criteria of ABPA were evaluated in the present study. Six patients each received a diagnosis of ABPA serologic positive (ABPA-S), ABPA with central bronchiectasis (ABPA-CB), and ABPA with central bronchiectasis and other radiologic features (ABPA-CB-ORF). RESULTS: The spirometric changes in the ABPA-S group (group 1) were mild, in the ABPA-CB group (group 2) were moderate, and in the ABPA-CB-ORF group (group 3) were severe. Absolute eosinophil count was raised in each group but was maximum (1,233 micro L) in severe form of disease (group 3). Specific IgE against A fumigatus was raised in each group, and the maximum was 47.91 IU/mL in ABPA-CB-ORF. CT scan findings of the ABPA-S group were normal without central bronchiectasis. The exacerbation in symptoms was maximum in group 3 compared to other groups. CONCLUSION: The present observations suggest that ABPA includes mild (ABPA-S), moderate (ABPA-CB), and severe (ABPA-CB-ORF) forms of disease. It is recommended, therefore, that the disease should be diagnosed early, treated at the mild form of disease (ABPA-S), and prevented from leading to ABPA-CB or ABPA-CB-ORF.     

Aspergillosis and atopy in cystic fibrosis

Forty-six patients with cystic fibrosis (CF) were studied for colonization and sensitization by Aspergillus organisms. The fungus was cultured from 21 of 37 (57%) patients who produced sputum. The non-CF sputum isolation rate was 6.5%. Sputum hyphae were seen in 95% of patients with positive cultures. Sputum eosinophilia accompanied colonization by Aspergillus. Aspergillus precipitins were found in 37% of CF patients; positive immediate skin tests were found in 39%. "Atopy" defined by skin test criteria was found in 46%. All of these findings were more common in patients with more severe disease (p less than 0.05). CF patients had predominant mold sensitivity in contrast to predominant pollen sensitivity in a control group of asthmatic subjects. Serum IgE concentrations were increased in 22% of CF patients. CF patients who had increased serum concentrations of IgE were more likely to have a family history of atopy. Wheezing was more common in those who were atopic, especially the group with predominant mold sensitivity who had more severe disease. Four patients fulfilled the diagnostic criteria for allergic bronchopulmonary aspergillosis (ABPA) during the time of study and follow-up. A fifth patient had ABPA diagnosed before the study. The incidence of ABPA during a 2-yr period in our CF population was 11%.     

变应性支气管肺曲霉病七例临床特点分析

目的 探讨变应性支气管肺曲霉病( ABPA)的临床特征、影像学特点、诊断和治疗方法,以做到早期诊断及早期治疗.方法 回顾性分析解放军总医院2010年3月至2011年5月确诊的7例ABPA患者的临床资料.结果 7例中,男4例,女3例,平均年龄为(33±16)岁.在确诊ABPA前,曾被误诊为支气管哮喘(简称哮喘)6例,肺部感染3例,肺结核2例,支气管扩张1例.主要临床表现为咳嗽6例,咳痰5例,咯血4例(其中3例为黑褐色痰),喘息3例,气短3例,发热2例.7例外周血中总IgE均升高,中位数为3040 U/ml.7例外周血中嗜酸粒细胞比均升高,中位数为0.19.6例外周血中嗜酸粒细胞绝对值升高,中位数为1.84×109/L;6例曲霉皮肤点刺试验阳性;5例血清特异性烟曲霉IgE抗体升高,平均为(22±15) kU/L;4例血清特异性烟曲霉IgG抗体升高,平均为(108±96) mg,/L.胸部CT主要表现为双肺多发性斑片状影、中心型支气管扩张及支气管黏液栓形成.5例患者接受口服糖皮质激素(简称激素)联合抗真菌药物治疗.结论 ABPA主要临床特点为常有哮喘病史,胸部影像学显示游走性或固定性肺部浸润影或中心型支气管扩张,外周血中嗜酸粒细胞、血清总IgE水平和血清烟曲霉特异性IgE抗体均升高.对哮喘合并支气管扩张的患者应高度警惕ABPA的可能,应常规进行曲霉皮肤试验筛查,必要时行外周血总IgE及胸部CT检查,以提高ABPA的诊断率.口服激素联合抗真菌药物对ABPA治疗有效.对ABPA患者应注意规律随诊并监测病情的变化,防止病情复发加重.     

Uncertain areas in the diagnosis of allergic bronchopulmonary aspergillosis in patients with asthma

Background and objectiveThe prevalence of allergic bronchopulmonary aspergillosis (ABPA) in patients with bronchial asthma remains unknown. We evaluated the roles of various laboratory tests in the diagnosis of ABPA, including, skin prick test (SPT) for Aspergillus fumigatus (Af), and serum Af specific IgE and IgG antibody measurement.MethodsA total of 50 asthma patients with more than 1000 cell/μL of peripheral blood eosinophils were prospectively collected between January 2007 and September 2011. Evaluations using SPT for Af, serum total IgE and specific IgE antibody to Af by CAP system, IgG antibody to Af by enzyme immunoassay (EIA) or CAP system were performed according to the essential minimal criteria for the diagnosis of ABPA – asthma, immediate cutaneous reactivity to Af, elevated total IgE, and raised Af specific IgE and IgG.ResultsAmong 50 patients, three patients (6.0%) were diagnosed as ABPA, of whom each confirmed five items of the essential minimal diagnostic criteria for the diagnosis of ABPA. Six patients (12.0%) showed negative responses to Af in SPT, but positive responses in specific IgE by CAP system. Eight patients (16.0%) showed negative responses to IgG to Af by CAP system, but positive responses by enzyme immunoassay (EIA).ConclusionsSPT and serum IgE to Af measurement by CAP system should be performed simultaneously. It is reasonable to set up cut-off values in Af specific IgE/IgG by CAP system for the differentiation of ABPA from Af sensitised asthma patients.     

Serum IgE and IgG antibody activity against Aspergillus fumigatus as a diagnostic aid in allergic bronchopulmonary aspergillosis.

Serum IgE and IgG antibody activity against Aspergillus fumigatus was measured in 3 groups of subjects by 2 different immunologic methods. Group A consisted of 23 patients with allergic bronchopulmonary aspergillosis (ABPA). Group B was composed of 19 patients with extrinsic asthma who had marked immediate type skin reactivity to A. fumigatus (prick skin test, 3 or 4+) but no other manifestation of ABPA. Group C, the control group, was composed of 12 healthy subjects. Two immunological methods, including a solid-phase polystyrene tube radioimmunoassay and an iodine-125-labeled, A. fumigatus antigen radioimmunoassay, were used to study each patient's serum sample, so as to demonstrate IgE antibody activity against A. fumigatus (IgE-Af) and IgG antibody activity against A. fumigatus (IgG-Af). Both IgE-Af and IgG-Af were significantly greater among patients in Group A than among those in Group B and Group C, as measured by both methods (P is less than 0.001). The results of this study suggest that either method can be used as a diagnostic aid for ABPA. These methods may provide a laboratory test permitting diagnosis of ABPA in its early stages before bronchial or pulmonary destruction occurs.     

Drug hypersensitivities: which room for biological tests?

Drug allergic reactions frequently represent a serious diagnostic problem. In this paper we summarise the most relevant data published in recent years on the diagnostic reliability of the in vitro techniques in drug allergy diagnosis. The lymphocyte transformation test (LTT) offers a sensitivity of 58% in the diagnosis of late allergic reactions to betalactams and 64.5% in the immediate allergic reactions. The basophil activation test and the antigen-specific sulphidoleukotriene determination have an acceptable diagnostic reliability in muscle relaxant drug-induced reactions and in betalactam allergy. BAT sensitivity in betalactam allergy was 50.7% and its specificity 93.3%, whereas CAP had a sensitivity of 36.7% and a specificity of 83.3%, and CAST, a sensitivity of 47.7% and a specificity of 83.3%. For NSAID hypersensitivity, BAT sensitivity was 63.3% and specificity 93.3%, CAST sensitivity was 38.3% and specificity 76.6%. BAT sensitivity in metamizol allergy was 42.3% and the specificity 100% and CAP was negative in all the 17 cases in which it was performed. The joint use of BAT and CAP (specific IgE) allows diagnosis of 65.2% of the betalactam allergic patients with a specificity of 83.3%. The combined use of CAST and BAT in metamizol allergy detects 76% of the cases and 76.9% when associating the skin tests. In NSAID hypersensitivity, the joint use of BAT and CAST does not increase the diagnostic reliability of BAT alone. BAT is a non-invasive useful technique in the in vitro diagnosis of betalactam and metamizol allergy, and NSAID hypersensitivity.     

烟曲霉特异性免疫球蛋白E阳性患者临床特点及吸入性过敏原过筛试验对变应性支气管肺曲霉菌病的诊断价值研究

背景 变应性支气管肺曲霉菌病(ABPA)临床辨识度低,诊断困难,误诊、漏诊率高.而吸入性过敏原过筛试验(Phadiatop)可检测吸入性过敏原混合物的特异性免疫球蛋白E(sIgE).目前Phadiatop在烟曲霉sIgE阳性人群及ABPA人群临床诊治中的应用尚未普及.目的 探讨烟曲霉sIgE阳性患者的临床特点及Phad...     

变态反应性支气管肺曲霉病研究进展

变态反应性支气管肺曲霉病(allergic bronchopulmonary aspergillosis,ABPA)与烟曲霉引起的变态反应相关,常发生在哮喘和肺囊性纤维化患者中.ABPA可引起血清总IgE水平升高,外周血嗜酸粒细胞增多,肺浸润和中心性支气管扩张,严重者可导致肺纤维化等肺组织的不可逆破坏.故ABPA的早期明确诊断和及时治疗十分重要.本文将对近年来ABPA的发病机制、临床分期、诊断标准、辅助检查及治疗研究新进展进行介绍.     

Correlation of IgE antibody titer to Aspergillus fumigatus with decreased lung function in cystic fibrosis

Obstructive pulmonary disease is a typical feature of cystic fibrosis (CF) and is often associated with bronchial hyperreactivity. Positive skin-test reactions to Aspergillus fumigatus antigens are frequently seen even in nonatopic patients with CF. Full-fledged allergic bronchopulmonary aspergillosis (ABPA) has been estimated to occur in 10% of patients with CF. The relationship between lung function and presence of IgE antibodies to Aspergillus antigens in patients without ABPA is not clear. In 148 outpatients with CF (aged 6-34 years) specific immunoglobulin E (IgE) to Aspergillus fumigatus antigens, basic lung-function parameters, and bronchial response to salbutamol were measured. Multiple regression was performed for age, weight as percentile for actual height (indicating general condition), and Aspergillus RAST. Aspergillus IgE was present in 46% of patients; 19% had RAST class 3 or 4. Independent negative correlations of Aspergillus RAST with FEV1, FEF50%, FEF25%, RV, Chrispin Norman score, and sRaw (P less than 0.05) were found. Bronchodilator sensitivity did not correlate significantly with age and weight percentile. However, Aspergillus RAST did correlate significantly with bronchodilator response measured by sRaw (P less than 0.05). High titers of Aspergillus RAST might serve as a selective criterion for patients to be included in future studies evaluating broncholytic or antiphlogistic therapies.     

Successful treatment of allergic bronchopulmonary aspergillosis with erythromycin and fluconazole]

A 30-year-old woman was admitted to our hospital because of productive cough, wheezing, and the disclosure of abnormal shadows on chest X-ray films. The patient was given a diagnosis of allergic bronchopulmonary aspergillosis (ABPA) based on eight findings: asthma, eosinophilia, elevated serum IgE concentrations, immediate skin reactivity to Aspergillus antigen, the presence of precipitating antibodies against Aspergillus antigen, lung infiltration, central bronchiectasis, and repeated culture of Aspergillus fumigatus in sputum. Because she refused steroids, we administered erythromycin. The volume of her sputum subsequently decreased, her symptoms were brought under control, and her serum IgE fell, but the lung infiltrates did not clear. Discontinuation of erythromycin resulted in exacerbation of the patient's asthmatic symptoms, with high fever, increased sputum volume and IgE levels, and worsening lung infiltrates. These symptoms responded well to oral prednisolone medication, but sputum culture was still positive for Aspergillus fumigatus. Following discontinuation of prednisolone, the patient was treated with erythromycin, to which oral fluconazole was added for 16 months. Subsequent sputum cultures were negative for Aspergillus fumigatus, and for 7 years thereafter the patient remained in remission. Erythromycin and anti-fungal drugs may be worth trying in cases of allergic bronchopulmonary aspergillosis.     

Immunology of allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity lung disease caused predominantly by the ubiquitous fungus Aspergillus fumigatus. ABPA is characterized by eosinophilia, fleeting pulmonary infiltrates, central bronchiectasis, elevated serum IgE and Aspergillus specific IgG and IgE. The pathogenetic mechanism implicated in ABPA is not completely understood. The cytokine response detected in ABPA patients is of a CD4+ Th2 type as evidenced by the production of IL-4, IL-5, and very little or no IFN-g on stimulation of T-lymphocytes with Aspergillus antigens. Animal model studies using wild type and gene knockout mice indicate a more precise mechanism of lung injury in antigen exposed animals. IL-4 knockout mice invariably showed a predominant Th1 response. B-cell deficient and IgE knockout mice exposed to A. fumigatus antigens showed airway response similar to wild type mice indicating a lesser role for IgE and other antibodies in the pathogenesis of murine experimental ABPA. RAG negative mice failed to show airway hyperreactivity response, although airway hyperreactivity was induced in naive RAG negative animals when T-cells from wild type Aspergillus immunized mice were transferred. The results of these studies indicate a multi-factorial immunopathogenesis in ABPA, which include T-cells, IgE, eosinophils, mast cells, and various cytokines and chemokines.     

Clinical significance of hyperattenuating mucoid impaction in allergic bronchopulmonary aspergillosis: an analysis of 155 patients

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) is a disease that presents with diverse clinicoradiologic manifestations. High-attenuation mucus (HAM) is a characteristic radiologic finding seen in patients with ABPA; however, the clinical significance of the entity remains unknown. AIMS AND OBJECTIVES: To describe the outcome of patients with ABPA who were demonstrated to have HAM, and compare with the outcome of patients without HAM. METHODS: All consecutive patients with asthma presenting to the Chest Clinic of this institute over a 4-year period were screened with an Aspergillus skin test. Patients with positive findings were further investigated, and the diagnosis of ABPA was confirmed based on predefined criteria. The patients were further classified into two groups based on the presence of HAM on HRCT scan. RESULTS: During the study period, 755 patients were screened for ABPA using the Aspergillus skin test; 291 patients (38.5%) had positive findings, and ABPA was diagnosed in 155 patients (mean age, 33.98 years; 76 women). Twenty-nine patients (18.7%) with ABPA were identified to have HAM on HRCT scans at presentation. The baseline characteristics were similar between the two groups, but patients with HAM had higher mean eosinophil counts, higher mean serum total IgE, and higher Aspergillus fumigatus-specific IgE levels. On multivariate analysis, both the severity of bronchiectasis and HAM predicted relapse of ABPA (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13 to 1.42; and OR, 3.61; 95% CI, 1.23 to 10.61, respectively). Failure to achieve complete remission was influenced by the severity of bronchiectasis but not by HAM (OR, 1.55; 95% CI, 1.29 to 1.85; and OR, 3.41; 95% CI, 0.89 to 13.1, respectively). CONCLUSIONS: HAM impaction in ABPA is associated with initial serologic severity and frequent relapses but does not seem to influence complete remission.     

Allergic bronchopulmonary aspergillosis. Apropos of 30 cases

Thirty cases of allergic bronchopulmonary aspergillosis (ABPA) were treated between 1967 and 1981. Developing in patients with a history of chronic asthma (28 of the 30 cases), the initial manifestations of ABPA developed after long periods (an average of 29 years after the onset of the asthma). Chest radiography demonstrated recurrent labile infiltrates in 28 cases, segmental or lobar atelectasis in 7, and proximal bronchiectasis in 16 cases. A circulating eosinophilia was a constant finding, but this varied with time. Immunologic investigations gave positive skin tests, 19 of the 30 patients only presenting a cutaneous reaction delayed until the 6th hour. Total IgE, determined in 18 cases, varied between 600 and 9400 IU/ml (RIST), with identification of specific IgE for Aspergillus in all cases, though to varying degrees. Serial measurements of total IgE levels showed co-existence of an acute progression of the affection and elevated total IgE in 3 cases, but no correlation was found between serum IgE levels and the severity or chronicity of the disease. Physiopathologic features included immediate and partially delayed hypersensitivity to Aspergillus fumigatus. The frequency of ABPA during the course of mucoviscidosis suggests, by analogy, that a local factor may exist which favorizes Aspergillus fumigatus proliferation in patients with ABPA alone.