Allergic bronchopulmonary aspergillosis - CHEST Publications ...

Table 5—Criteria Used for the Diagnosis of ABPA
Rosenberg-Patterson criteria 6,9
Major criteria (mnemonic ARTEPICS)
A Asthma
R Roentgenographic fleeting pulmonary opacities
T Skin test positive for Aspergillus (type I reaction,
immediate cutaneous hyperreactivity)
E Eosinophilia
P Precipitating antibodies (IgG) in serum
I IgE in serum elevated ( 1,000 IU/mL)
C Central bronchiectasis
S Serums A fumigatus-specific IgG and IgE (more than
twice the value of pooled serum samples from patients with
asthma who have Aspergillus hypersensitivity)
Minor criteria
Presence of Aspergillus in sputum
Expectoration of brownish black mucus plugs
Delayed skin reaction to Aspergillus antigen (type III
reaction)
The presence of six of eight major criteria makes the diagnosis
almost certain; the disease is further classified as ABPA-S or
ABPA-CB on the absence or presence of central
bronchiectasis, respectively
Minimal diagnostic criteria for ABPA 32
Minimal ABPA-CB
Asthma
Immediate cutaneous hyperreactivity to Aspergillus antigens
Central bronchiectasis
Elevated IgE
Raised A fumigatus-specific IgG and IgE
Minimal ABPA-S
Asthma
Immediate cutaneous hyperreactivity to Aspergillus antigens
Transient pulmonary infiltrates on chest radiograph
Elevated IgE
Raised A fumigatus-specific IgG and IgE
specific IgE and IgG levels can help in confirming
the diagnosis of ABPA because values of IgG/IgE
more than twice the pooled serum samples from
patients with asthma are raised only in ABPA. 113,132
We currently use a cutoff value of 1,000 IU/mL for
the diagnosis of ABPA. 22,23 While investigating a
patient with asthma, we first perform an Aspergillus
skin test. Once it is positive, the total serum IgE
levels are done. 131 If the value is 1,000 IU/mL, we
perform the other tests (Fig 5). If the value is
between 500 and 1,000 IU/mL, the next step is analysis
of A fumigatus-specific IgE and IgG antibodies. If the
levels are raised, the patient is followed up every 6 weeks
with total IgE levels. If the absolute value rises 1,000
IU/mL or there is a rising trend with clinical deterioration,
the treatment is started. If the value is between 500 and
1,000 IU/mL and IgE and IgG specific to A fumigatus are
not raised, the patient is followed up with a yearly total
IgE levels (Fig 5).
Natural History
The natural history of ABPA is not well characterized.
9,128,133–136 An early diagnosis and initiation of
systemic corticosteroids are essential to prevent irreversible
damage. 137 The natural course of ABPA can
be best understood if we recognize the two important
classification schemes (Tables 6 and 7) of ABPA:
(1) classification of ABPA into five stages as described
by Patterson et al 8 , and (2) classification of
ABPA into ABPA-S (seropositive ABPA) and ABPA-CB
(ABPA with central bronchiectasis) described by
Greenberger et al. 12
Staging of ABPA: ABPA has been classified into
five stages, but a patient does not necessarily
progress from one stage to the other sequentially
(Table 6). Patients in stage I or III (depending on
whether or not the disorder has been previously
diagnosed) are generally symptomatic with radiographic
infiltrates, raised IgE levels, and elevated A
fumigatus-specific IgG/IgE. 23 With glucocorticoid
therapy, there is clearing of radiographic opacities
with a 35 to 50% decline in IgE levels by 6 weeks
that defines remission or stage II. The aim of
glucocorticoid therapy is not normalization of total
IgE levels because the immunologic process goes in
remission with just 35 to 50% decline in IgE levels,
and in many patients the IgE levels do not come to
down to normal values. The test needs to be often
repeated during therapy to determine the lowest
level for an individual patient that serves as the
baseline for that particular patient. Treatment is
continued for 6 to 9 months, and if there are no
exacerbations over the next 3 months after stopping
therapy, we label it as “complete remission.” Patients
in complete remission are followed up by serial IgE
levels every 6 months for the first year and then
annually. Even in patients with complete remission,
the IgE levels decline to normal in only a minority of
patients, 128,133 and the aim of glucocorticoid therapy
is not achievement of normal IgE levels. 79 A complete
remission does not imply a permanent remission
because exacerbations can occur several years
after remission. 135 Almost 25 to 50% of the patients
have relapse/exacerbation of the disease, defined by
doubling of the baseline IgE levels (stage III). 8,9,22
Patients in stage IV require oral glucocorticoids for
control of asthma (glucocorticoid-dependent asthma)
or ABPA (glucocorticoid-dependent ABPA). 10,22 Patients
in stage V are those with widespread bronchiectasis
and varying degrees of pulmonary dysfunction.
We define patients in stage V if they have
hypercapnic respiratory failure (Pao 2 60 mm Hg
and Paco 2 45 mm Hg) and/or cor pulmonale.
Even in stage V ABPA, the disease can be clinically
as well as immunologically active requiring longterm
glucocorticoid therapy. 136,138
812 Global Medicine
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