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Figure 7. Proportion metaanalysis showing the prevalence of allergic bronchopulmonary aspergillosis in patients with CF (random effects model). in CF should not be based solely on serology and skin test results, and prolonged testing might be required to make a definite diagnosis (Table 10). The treatment of ABPA in CF is not very different from that of ABPA in bronchial asthma, except minimal data are available to formulate conclusive treatment recommendations for ABPA in CF. The treatment issues are further complicated because pulmonary exacerbations in a patient with ABPA and CF could be related to ABPA or pulmonary infection, and 818 Global Medicine Downloaded From: http://jupcvss.chestpubs.org/ on 08/01/2013
Table 10—Consensus Conference Proposed Diagnostic and Screening Criteria for ABPA in CF 202 Classic diagnostic criteria 1. Acute or subacute clinical deterioration (cough, wheeze, and other pulmonary symptoms) not explained by another etiology 2. Serum total IgE levels 1,000 IU/mL 3. Immediate cutaneous reactivity to Aspergillus or presence of serum IgE antibody to A fumigatus 4. Precipitating antibodies to A fumigatus or serum IgG antibody to A fumigatus 5. New or recent abnormalities on chest radiograph or chest CT scan that have not cleared with antibiotics and standard physiotherapy Minimal diagnostic criteria 1. Acute or subacute clinical deterioration (cough, wheeze, and other pulmonary symptoms) not explained by another etiology 2. Total serum IgE levels 500 IU/mL. If total IgE level is 200– 500 IU/mL, repeat testing in 1–3 mo is recommended 3. Immediate cutaneous reactivity to Aspergillus or presence of serum IgE antibody to A fumigatus 4. One of the following: (1) precipitins to A fumigatus or demonstration of IgG antibody to A fumigatus; or (2) new or recent abnormalities on chest radiography (on chest radiography or chest CT scan that have not cleared with antibiotics and standard physiotherapy) Screening for ABPA in CF 1. Maintain a high level of suspicion for ABPA in patients with CF 2. Determine the total serum IgE levels annually. If the total serum IgE levels is 500 IU/mL, perform A fumigatus skin test or use an IgE antibody to A fumigatus. If results are positive, consider diagnosis on the basis of minimal criteria 3. If the total serum IgE levels is 200–500 IU/mL, repeat the measurement if there is increased suspicion for ABPA and perform further diagnostic tests (immediate skin test reactivity to A fumigatus, IgE antibody to A fumigatus, A fumigatus precipitins, or serum IgG antibody to A fumigatus, and chest radiography) hence continuous assessment may be required over months with repeat performance of all the serologic investigations for ABPA before a decision to treat an individual case is made. 202 ABPA Without Bronchial Asthma: ABPA may occasionally develop in an individual without preexisting asthma. We have performed a systematic MEDLINE search for the occurrence of ABPA without bronchial asthma. 100 In total they included 36 cases reported across the globe; two cases demonstrated bronchodilator reversibility, 203 and one showed airway hyperresponsiveness to methacholine challenge. 204 Most of the cases demonstrated hypersensitivity to A fumigatus, but three cases showed hypersensitivity to Helminthosporium, 203 and one case each to Aspergillus niger. 205,206 Because of the absence of bronchial asthma, these cases are often mistaken initially for other pulmonary disorders like bronchogenic carcinoma 206–208 or pulmonary tuberculosis. 100 ABPA Complicating Other Conditions: Occasionally ABPA has been reported to complicate other lung diseases like idiopathic bronchiectasis, 209 post-tubercular bronchiectasis, 210 bronchiectasis secondary to Kartagener syndrome, 211 COPD, 212 and in patients with chronic granulomatous disease and hyper IgE syndrome. 213 However, these are case reports or small case studies, and larger observations are required to definitely establish an association. Coexistence of ABPA and Aspergilloma: The serologic findings of ABPA have also been reported in patients with aspergilloma 214–224 and chronic necrotizing pulmonary aspergillosis. 225 This ABPA-like syndrome probably represents a true hypersensitivity reaction consequent to the colonization of Aspergillus in long-standing pulmonary cavities and the continuous release of Aspergillus antigens that leads to immunologic activation. 214,215 Most patients show a brisk response to glucocorticoids. 214–217,224 Allergic Bronchopulmonary Mycosis: Allergic bronchopulmonary mycosis is the occurrence of an ABPA-like syndrome due to non-A fumigatus fungal organisms. A variety of fungal agents (Table 11) have been reported to cause this syndrome, but the frequency is far less when compared to ABPA. 218,226–240 ABPA and Allergic Aspergillus Sinusitis: Allergic Aspergillus sinusitis (AAS) is a clinical entity in which mucoid impaction akin to that of ABPA occurs in the paranasal sinuses. 241 The pathogenesis is also similar to ABPA and represents an allergic hypersensitivity response to the presence of fungi within the sinus cavity. 242 The patient is often asymptomatic or can manifest with symptoms of nasal obstruction, rhinor- Table 11—Fungi Implicated in the Causation of Allergic Bronchopulmonary Mycosis Fungi Study/Year A niger Sharma et al 218 /1985 Helminthosporium spp Dolan et al 226 /1970 Penicillium spp Sahn and Lakshminarayan 227 /1973 Aspergillus ochraceus Novey and Wells 228 /1978 Stemphylium spp Benatar et al 229 /1980 Aspergillus terreus Laham et al 230 /1981 Drechslera spp McAleer et al 231 /1981 Torulopsis spp Patterson et al 232 /1982 Mucor-like spp Patterson et al 232 /1982 Candida spp Akiyama et al 234 /1984 Pseudallescheria spp Lake et al 235 /1990 Bipolaris spp Lake et al 236 /1991 Curvularia spp Lake et al 236 /1991 Schizophyllum spp Kamei et al 237 /1994 Fusarium spp Backman et al 238 /1995 Cladosporium spp Moreno-Ancillo et al 239 /1996 Saccharomyces spp Ogawa et al 240 /2004 www.chestjournal.org CHEST / 135 /3/MARCH, 2009 819 Downloaded From: http://jupcvss.chestpubs.org/ on 08/01/2013
Page 1 and 2: CHEST Global Medicine Allergic Bron
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Page 17 and 18: 27 Tillie-Leblond I, Tonnel AB. All
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