High-attenuation Mucus Research Articles

Bronchiectasis Severity Index and FACED scores in patients with allergic bronchopulmonary aspergillosis complicating asthma: do they correlate with immunological severity or high-attenuation mucus?

Background The utility of two disease-severity indices, namely bronchiectasis severity index (BSI) and FACED score in allergic bronchopulmonary aspergillosis (ABPA) remains unknown. Objective To correlate the BSI and FACED scores with immunological parameters (serum IgE [total and A. fumigatus-specific], A. fumigatus-specific IgG, blood eosinophil count), and high-attenuation mucus on chest computed tomography in ABPA. The secondary objectives were to evaluate the correlation between BSI and FACED scores and correlate the BSI/FACED scores with the bronchiectasis health questionnaire (BHQ) and Saint George’s Respiratory Questionnaire (SGRQ). Methods We included treatment-naïve ABPA subjects with bronchiectasis in a prospective observational study. We computed the BSI and FACED scores for each subject before initiating treatment. The subjects also completed two quality-of-life questionnaires (BHQ and SGRQ). Results We included 91 subjects. The mean (standard deviation) BSI and FACED scores were 3.43 (3.39) and 1.43 (1.27). We found no correlation between BSI or FACED with any immunological parameter or high-attenuation mucus. There was a strong correlation between BSI and FACED scores (r = 0.76, p < 0.001). We found a weak correlation between BSI and BHQ/SGRQ and FACED and SGRQ. Conclusion We found no correlation between BSI and FACED with immunological parameters in ABPA. However, we found a significant correlation between BSI and FACED and a weak correlation between SGRQ and BHQ. ABPA likely requires a separate disease-severity scoring system.

High attenuation mucus in bronchi with allergic bronchopulmonary mycosis.

High-attenuation mucus (HAM) is a specific manifestation of allergic bronchopulmonary mycosis (ABPM) on chest computed tomography (CT). To compare the diagnostic accuracy of the two definitions of HAM and to clarify the clinical and radiographic characteristics of HAM-positive and HAM-negative ABPM. CT images at the diagnosis of ABPM using Asano's criteria were retrospectively analysed. In Study #1, radiographic data obtained using the same CT apparatus in a single institute were analysed to determine the agreement between the two definitions of HAM: a mucus plug that is visually denser than the paraspinal muscles or that with a radiodensity ≥70 Hounsfield units. In Study #2, HAM was diagnosed by comparison with the paraspinal muscles in patients with ABPM reporting to 14 medical institutes in Japan. In Study #1, 93 mucus plugs from 26 patients were analysed. A substantial agreement for HAM diagnosis was observed between the two methods, with a κ coefficient of 0.72. In Study #2, 60 cases of ABPM were analysed; mucus plugs were present in all cases and HAM was diagnosed in 45 (75%) cases. The median A. fumigatus-specific IgE titre was significantly lower in HAM-positive patients than in HAM-negative patients (2.5 vs. 24.3 UA /mL, p = .004). Nodular shadows were observed more frequently in the airways distal to HAM than in those distal to non-HAM mucus plugs (59% vs. 32%, p < .001). In conclusion, agreement between the two methods to diagnose HAM was substantial. HAM was associated with some immunological and radiographic characteristics, including lower levels of sensitization to A. fumigatus and the presence of distal airway lesions.

Sensitivity and specificity of LDBio Aspergillus ICT lateral flow assay for diagnosing allergic bronchopulmonary aspergillosis in adult asthmatics.

Aspergillus fumigatus-specific IgG estimation is crucial for diagnosing allergic bronchopulmonary aspergillosis (ABPA). A point-of-care LDBio immunochromatographic lateral flow assay (LFA) had 0%-90% sensitivity to detect IgG/IgM antibodies against A. fumigatus. To assess the accuracy of LDBio-LFA in diagnosing ABPA, using the modified ISHAM-ABPA working group criteria as the reference standard. The secondary objective was to compare the diagnostic performance between LDBio-LFA and A. fumigatus-specific IgG (cut-offs, 27 and 40 mgA/L), using a multidisciplinary team (blinded to A. fumigatus-IgG and LDBio-LFA results) diagnosis of ABPA as the reference standard. We prospectively enrolled adult subjects with asthma and ABPA. We performed the LDBio-LFA per the manufacturer's recommendations. We used the commercially available automated fluorescent enzyme immunoassay for measuring serum A. fumigatus-specific IgG. We used the same serum sample to perform both index tests. The tests were performed by technicians blinded to the results of other tests and clinical diagnoses. We included 123 asthmatic and 166 ABPA subjects, with a mean ± SD age of 37.4 ± 14.4 years. Bronchiectasis and high-attenuation mucus were seen in 93.6% (146/156) and 24.3% (38/156) of the ABPA subjects. The sensitivity and specificity of LDBio-LFA in diagnosing ABPA were 84.9% and 82.9%, respectively. The sensitivity of serum A. fumigatus-specific IgG ≥27 mgA/L was 13% better than LDBio-LFA, with no difference in specificity. There was no significant difference in sensitivity and specificity between LDBio-LFA and serum A. fumigatus-IgG ≥40 mgA/L. LDBio-LFA is a valuable test for diagnosing ABPA. However, a negative test should be confirmed using an enzyme immunoassay.

Clinical, Microbiological, Serological and Radiological Profile of Patients With Mild-Moderate and Severe Allergic Bronchopulmonary Aspergillosis (ABPA).

Objective Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction to Aspergillus antigen mostly Aspergillus fumigatus that occurs almost exclusively in patients with asthma and cystic fibrosis. ABPA is an underdiagnosed and undertreated disease because of its presentation with various grades of severity in asthma patients. Data available regarding the clinical, serological, and radiological profile of ABPA patients is limited due to lack of consensus on diagnostic criteria and treatment guidelines. Thus ABPA is a significant disease, especially in the Indian population where the incidence of allergic diseases like asthma is on the rise. Methods This prospective study was conducted in the Department of Pulmonary Medicine at one of the tertiary centers of north India. All consecutive patients diagnosed withallergic bronchopulmonary aspergillosis (ABPA) from 1st January 2017to 30th September 2017 were included in the study. A total of 67 consecutive patients diagnosedwithbronchial asthma were included in the study. The diagnosis of ABPA was based upon either criterion given by Rosenberg and Patersonor the International Society of Human and Animal Mycology (ISHAM) criteria. Patients diagnosed with ABPAwere finally divided into mild, moderate, and severe. Results The majority of patients showed an obstructive pattern on spirometry and moderate to severe obstruction was the most common pattern observed among patients who had an obstructive pattern on spirometry. Also, all three patients with the mixed pattern on spirometry had severe disease. Serological analysis revealed that patients in the moderate category had a higher level of absolute eosinophil count (AEC), total IgE, and Aspergillus-specific IgE antibodies, especially in patients who hadeither high attenuation mucus (HAM) or centrilobular nodules on their high-resolution computed tomography (HRCT) scan. Conclusion ABPA is a disease of divergent presentation. We concluded to have alternate or add-on criteria for the classification of ABPA which was not based on the sequelae of chronic inflammatory changes in the lungs.

Long-term follow-up of allergic bronchopulmonary aspergillosis treated with glucocorticoids: A study of 182 subjects.

The long-term outcomes of allergic bronchopulmonary aspergillosis (ABPA) are poorly characterised. We retrospectively included treatment-naïve subjects of acute stage ABPA-complicating asthma from three randomised trials. All the subjects received oral prednisolone for 4 months and were monitored every 6 weeks for 6 months and then every 6 months. Our primary objective was to estimate the incidence rate and the frequency of subjects experiencing ABPA exacerbation. The key secondary objectives were to evaluate the factors predicting ABPA exacerbation and the changes in serum total IgE seen during treatment. We included 182 subjects. Eighty-one (44.5%) patients experienced 120 exacerbations during 512 patient-years of follow-up. The incidence rate of ABPA exacerbations was 234/1000 patient-years. Most (73/81, 90.1%) subjects experienced ABPA exacerbation within three years of stopping therapy. On multivariate logistic regression analysis, peripheral blood eosinophil count ≥1000 cells/μL (adjusted odds ratio [aOR] 2.43; 95% confidence interval (CI), 1.26-4.67), the extent of bronchiectasis (aOR 1.10; 95% CI, 1.03-1.18), age (aOR 0.97; 95% CI, 0.94-0.99), and female sex (aOR 2.16; 95% CI, 1.10-4.24) independently predicted ABPA exacerbation after adjusting for serum total IgE and high-attenuation mucus. The best cut-off for serum total IgE after 6 weeks for identifying treatment response and ABPA exacerbations was a 20% decline and a 50% increase, respectively. ABPA exacerbations were common within 3 years of stopping treatment. Age, female sex, peripheral blood eosinophilia and the extent of bronchiectasis predicted ABPA exacerbations. The optimal serum total IgE cut-off for defining ABPA response and exacerbations is a 20% decline and a 50% increase, respectively.

Allergic bronchopulmonary aspergillosis in identical twins: Effectiveness of dupilumab

Allergic bronchopulmonary aspergillosis in identical twins: Effectiveness of dupilumab

Occurrence of Cystic Fibrosis Transmembrane Conductance Regulator Gene Mutations in Patients with Allergic Bronchopulmonary Aspergillosis Complicating Asthma.

Whether cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations contribute to the high prevalence of allergic bronchopulmonary aspergillosis (ABPA) in India remains unknown. We aimed to evaluate the occurrence of CFTR mutations in subjects with ABPA complicating asthma. We sequenced the CFTR gene using genomic DNA from blood on the Illumina NextSeq500 platform. Before undertaking zygosity analysis by genome analysis toolkit, the known or novel single nucleotide polymorphisms (SNPs) and indels were called. For rigorous analysis, we included only high-quality SNPs (scores > 500) and coverage ranging from 30 × 150x. We included 18, 12, and eight adult participants of ABPA, asthma, and healthy controls, respectively. The frequency of SNPs was higher in asthmatic subjects than ABPA or healthy controls, albeit not statistically significant (9/12 [75%] vs. 11/18 [61.1%] vs. 3/8 [37.5%], p = 0.24). Of the 38 subjects, 23 yielded 50 variants (healthy controls [n = 5], ABPA [n = 22], asthma [n = 23]) corresponding to six SNPs not previously linked with ABPA. Of these, four SNPs (rs213950, rs200735475, rs1800113, and rs1800136) were catalogued in the NCBI database. We identified two novel SNPs (chr7:117250703, chr7:117282655) in four (ABPA [n = 1], asthma [n = 3]) subjects without corresponding reference SNP. Most SNPs (85.5%) were heterozygous. The frequency of SNPs was higher in ABPA subjects with high-attenuation mucus (52.2%) and bronchiectasis (39.1%) than serological ABPA (8.7%). Our study suggests the role of CFTR mutations in the pathogenesis of ABPA. The SNPs in the CFTR gene may contribute to disease severity in ABPA. Larger studies are required to confirm our findings.

High attenuation mucus

High attenuation mucus

Pulmonary eosinophilia may indicate onset stage of allergic bronchopulmonary aspergillosis

BackgroundAllergic bronchopulmonary aspergillosis (ABPA) and chronic eosinophilic pneumonia (CEP) both display peripheral eosinophilia as well as pulmonary infiltration, together described as pulmonary eosinophilia, and differentiation is sometimes problematic. This study therefore examined the distinctions between ABPA with and without CEP-like shadows.MethodsThis retrospective cohort study from a single center included 25 outpatients (median age, 65 years) with ABPA diagnosed between April 2015 and March 2019, using criteria proposed by the International Society of Human and Animal Mycology (ISHAM), which focuses on positive specific IgE for Aspergillus fumigatus. Patients were assigned to either the eosinophilic pneumonia (EP) group or Non-EP group, defined according to findings on high-resolution computed tomography (HRCT). The EP group included patients with HRCT findings compatible with CEP; i.e., the presence of peripheral consolidation (p-consolidation) or ground-glass opacities (GGO), with no evidence of high-attenuation mucus. The Non-EP group comprised the remaining patients, who showed classical findings of ABPA such as mucoid impaction. Differences between the groups were analyzed.ResultsBaseline characteristics, frequency of a history of CEP (EP, 50% vs. Non-EP, 26%) and tentative diagnosis of CEP before diagnosis of ABPA (67% vs. 16%) did not differ significantly between groups. Although elevated absolute eosinophil count and Aspergillus-specific immunoglobulin E titers did not differ significantly between groups, the Non-EP group showed a strong positive correlation between these values (R = 0.7878, p = 0.0003). The Non-EP group displayed significantly higher levels of the fungal marker beta-D glucan (median, 11.7 pg/ml; interquartile range, 6.7–18.4 pg/ml) than the EP group (median, 6.6 pg/ml; interquartile range, 5.2–9.3 pg/ml). Both groups exhibited frequent recurrence of shadows on X-rays but no cases in the EP group had progressed to the Non-EP group at the time of relapse.ConclusionsThe ABPA subgroup with imaging findings resembling CEP experienced frequent recurrences, as in typical ABPA. In pulmonary eosinophilia, even if there are no shadows indicating apparent mucous change, the Aspergillus-specific immunoglobulin E level is important in obtaining an accurate diagnosis and in the selection of appropriate therapies for this type of ABPA.

Revisiting HRCT Features of ABPA

Allergic bronchopulmonary aspergillosis (ABPA) is an abnormal immune response (hyper-sensitivity) mounted against Aspergillus fumigatus in predisposed immunocompetent hosts. This entity is commonly seen in individuals with bronchial asthma and rarely in cystic fibrosis. Serological and radiological tests help to confirm the diagnosis. High resolution computed tomography (HRCT) is the radiological modality of choice for investigating ABPA subjects. The subjects with ABPA may present variably with no HRCT abnormalities, bronchiectasis, high attenuation mucus (HAM) and chronic fibrotic lung changes. The presence of HAM represents immunological severity and also indicates higher chances of relapse. HAM is pathognomonic for ABPA. HRCT findings of ABPA are reviewed in this article.

Nontuberculous mycobacterium presenting with high-attenuation mucus on chest computed tomography

Nontuberculous mycobacterium presenting with high-attenuation mucus on chest computed tomography

The clinical characteristics and prognosis of ABPA are closely related to the mucus plugs in central bronchiectasis.

IntroductionThe characteristics of Allergic Bronchopulmonary Aspergillosis (ABPA) based on its radiological classification is still unclear.ObjectivesTo investigate the clinical significances of ABPA patients with central bronchiectasis (ABPA‐CB) by different radiological classifications of mucus plugs.MethodsABPA‐CB patients from a pulmonary hospital between 2008 and 2015 were retrospectively included and analysed. According to the chest imaging in their first visit to physician, the ABPA‐CB patients were divided into two groups based on the presence of high‐attenuation mucus (HAM) or low‐attenuation mucus (LAM). The primary endpoint was ABPA relapse within 1 year since the glucocorticoid withdrawal. The relationship between the imaging findings and the clinical prognosis was illuminated.ResultsA total of 125 ABPA patients were analysed in this study. Compared to the LAM group, the HAM group presented higher blood eosinophil cells counts, higher rates of Aspergillus detection isolated in sputum and expectoration of brownish‐black mucus plugs, more affected lobes and segments, poorer pulmonary function and higher rate of relapse.ConclusionsThe clinical characteristics and prognosis of ABPA‐CB patients are closely related to its radiological phenotype of mucus plugs in the central bronchiectasis. Clinicians should promote a diversity of personalized treatments for different patients with different radiological characteristics.

EXACERBATIONS IN ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS: IDENTIFICATION OF RISK FACTORS AND DEVELOPING A PREDICTION MODEL

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: The course of allergic bronchopulmonary aspergillosis (ABPA), an immunological disorder complicating asthma and cystic fibrosis, is characterized by recurrent exacerbations. However, the factors predisposing to ABPA exacerbations remain unknown. Herein, we explore the risk factors and develop a prediction model to identify subjects at increased risk of exacerbation METHODS: We reviewed our database over a ten-year period to identify treatment-naïve subjects of ABPA having a minimum follow-up of 12 months. Clinical details, spirometry, IgE levels (total and Aspergillus fumigatus-specific IgE), and imaging findings (the number of lobes, and segments involved by bronchiectasis, presence of high-attenuation mucus [HAM]) were all retrieved. We reviewed the treatment details and the number of exacerbations during follow-up. We then compared the baseline parameters of subjects with and without exacerbation. Binomial logistic regression analysis was performed to identify factors predicting an exacerbation. Using the prediction model, we obtained the probability of exacerbation for each subject and a receiver operating characteristics (ROC) curve was constructed to predict an exacerbation. The degree of agreement between the model’s estimated probability of relapse and the actual relapse was assessed using the Hosmer-Lemeshow test for goodness-of-fit RESULTS: We included 428 subjects (median age 35.1 years, 54.4% men) with a median (IQR) follow-up of 40.6 (25-66.5) months. 206 subjects (48.1%) experienced a median (IQR) of 2 (1-2) exacerbations. The duration of asthma, symptom profile, the severity of obstruction, total IgE levels, and eosinophil counts were similar in subjects with and without ABPA exacerbation. The presence of bronchiectasis was also similar. However, the number of lobes and segments affected by bronchiectasis (median [IQR] of 7 [4-10] vs. 5 [2-9], p=0.008) were significantly higher in ABPA subjects experiencing exacerbations. Majority of the included subjects (79.2%) were treated with glucocorticoids, and this was not significantly different in the two study groups. The number of segments involved by bronchiectasis (OR [95% CI], 1.08 [1.02-1.14]) and the presence of HAM (OR [95% CI], 1.63 [1.01-2.62]) were the only factors independently associated with the development of ABPA exacerbation after adjusting for lung function, total and A.fumigatus-specific IgE levels. The model was moderate in predicting the occurrence of exacerbation (AUROC, 0.611) CONCLUSIONS: Exacerbations occur in nearly half of the patients with ABPA during follow-up. The presence of HAM at baseline and the number of segments affected by bronchiectasis independently predict the risk of developing an exacerbation CLINICAL IMPLICATIONS: The current model is moderately accurate in predicting future risk of exacerbation in ABPA. There may be factors other than HAM and bronchiectasis, resulting in exacerbation. DISCLOSURES: No relevant relationships Added 03/13/2019 by Ritesh Agarwal, source=Web Response, value=Consulting fee Removed 03/15/2019 by Ritesh Agarwal, source=Web Response No relevant relationships by Ashutosh Aggarwal, source=Web Response No relevant relationships by valliappan muthu, source=Web Response

Sinobronchial allergic mycosis syndrome in an elderly male

BackgroundAllergic bronchopulmonary aspergillosis (ABPA) and allergic fungal rhinosinusitis (AFRS) are characterized by hyper-responsiveness of the respiratory tract and the nasal cavity and paranasal sinuses, respectively to Aspergillus species and AFRS causes chronic rhinosinusitis. Herein, we report the first case of sinobronchial allergic mycosis (SAM) syndrome, defined as ABPA with concomitant AFRS, caused by Aspergillus fumigatus patient > 80 years.Case presentationAn 82-year-old male with interstitial pneumonia who returned for follow-up exhibited high-attenuation mucus plug in the right intermediate bronchial trunk, infiltration in the right lung field, and right pleural effusion on regular chest computed tomography (CT). We found unilateral central bronchiectasis in the right upper lobe. Similarly, CT scan of the paranasal sinuses revealed high-attenuation mucus plugs in left ethmoid sinuses. Biopsy specimens from the plugs in the right intermediate bronchial trunk and the left ethmoid sinuses revealed allergic mucin with layers of mucus eosinophils, eosinophil-predominant mixed inflammatory cell infiltrate and Aspergillus hyphae. The patient fulfilled all the major criteria for ABPA and AFRS, and was diagnosed with SAM syndrome. CT scan of the lung and paranasal sinuses revealed apparent amelioration after oral steroid therapy.ConclusionDespite mostly reported in relatively young patients, SAM syndrome can occur in elderly individuals as well.

Clinical features and reasons for missed diagnosis of allergic bronchopulmonary aspergillosis

Objective: To summarize the clinical features of allergic bronchopulmonary aspergillosis (ABPA) and analyze the common causes of missed diagnosis. Methods: The clinical data of patients with ABPA who were admitted into Qilu Hospital of Shandong University from October 2014 to November 2017 were retrospectively analyzed, including baseline data, eosinophil count in peripheral blood, serum total IgE, A. fumigates-specific antibody (sIgE, sIgG and sIgM), pulmonary function tests and chest CT, etc. Then the correlations between serum total IgE, sIgE and forced expiratory volume in one second (FEV1) as percentage of predicted value (FEV1%pred) was conducted, as well as that between serum total IgE, sIgE and FEV1/forced vital capacity (FEV1/FVC). The clinical features of the patients were summarized and the causes of missed diagnosis were analyzed. Results: There were 46 patients with ABPA (21 males and 25 females, 48.3±13.2 years old) in total. Only 2 cases (4.3%) were diagnosed after the first symptom onset, and 44 cases (95.7%) were treated repeatedly for many years before being diagnosed. The misdiagnoses were asthma (26 cases, 56.5%), bronchiectasis (13 cases, 28.3%), pneumonia (4 cases, 8.7%), pulmonary tuberculosis (3 cases, 6.5%), and lung cancer (4 cases, 8.7%). Common symptoms of ABPA included cough, expectoration, wheezing, chest tightness, fever, weight loss, chest pain, etc. Peripheral blood eosinophil count increased in 37 patients (80.4%). Serum total IgE in 37 patients (80.4%) were higher than 1 000 U/ml, and 9 cases (19.6%) were less than 1 000 U/ml. The positive rate of sIgE, sIgG and sIgM was 100.0%, 89.1% and 54.3%, respectively. All patients underwent pulmonary function tests and 35 cases (76.1%) had obstructive ventilation dysfunction, 5 cases (10.9%) with mixed ventilation dysfunction, 5 cases (10.9%) were normal and 1 case (2.2%) with restrictive ventilation dysfunction. All patients underwent Chest CT examination, 28 cases (60.9%) showed bronchiectasis, 8 cases (17.4%) manifested mucus plugs (among them, 4 cases with high-attenuation mucus) and 10 cases (21.7%) had other atypical imaging. Serum total IgE and sIgE had no correlations with FEV1%pred and FEV1/FVC. Conclusions: ABPA is characterized by recurrent episodes of wheezing, fleeting pulmonary opacities and bronchiectasis. The main reasons of misdiagnosis in ABPA patients were: atypical symptoms, variety of predisposing diseases, early atypical imaging changes, limitations and misunderstandings of screening indicators, interference with tumor markers, and the presence of pulmonary aspergillus overlap syndrome. The severity of asthma attacks is not related to the degree of fungal sensitization.

Prevalence of sensitization to Aspergillus flavus in patients with allergic bronchopulmonary aspergillosis.

Aspergillus fumigatus is the most common Aspergillus species worldwide; however, A. flavus has also been shown to be prevalent in North India. Herein, we investigate the prevalence of sensitization to A. flavus in subjects with allergic bronchopulmonary aspergillosis (ABPA). We also evaluate the occurrence of allergic bronchopulmonary mycosis (ABPM) due to A. flavus. Treatment-naive subjects with ABPA underwent sputum culture; and, skin testing, fungal-specific immunoglobulin E (IgE) and serum precipitation tests for A. fumigatus and A. flavus. Sensitization to A. flavus was diagnosed if any immunological test for A. flavus was positive in subjects with ABPA. ABPM was labelled as probable if sputum cultures grew A. flavus and A. flavus-specific IgE was greater than A. fumigatus-specific IgE; and, possible if only A. flavus-specific IgE was greater than A. fumigatus-specific IgE. Fifty-three subjects with a mean (SD) age of 34.2 (12.8) years were included. Sensitization to A. flavus was seen in 51 (96.2%) subjects, with overlap occurring in 49 (92.5%), 21 (39.6%), and 12 (22.6%) instances on fungal-specific IgE, skin prick test and precipitins, respectively. Sputum culture was positive in 18 (33.9%; A. flavus [n = 12], A. fumigatus [n = 6]) subjects. ABPM due to A. flavus was diagnosed in 16 (30.2%) subjects (10 probable, 6 possible). They were more likely to have high-attenuation mucus and a trend towards higher occurrence of sinusitis, compared to ABPA. We found a high occurrence of sensitization to A. flavus in subjects with ABPA. Subjects with A. flavus-related ABPM had a higher likelihood of high-attenuation mucus and probability of sinusitis. More studies are required to confirm this observation.

A review of 42 asthmatic children with allergic bronchopulmonary aspergillosis.

BackgroundAllergic bronchopulmonary aspergillosis (ABPA) in children with asthma, not associated with cystic fibrosis, is yet to receive the recognition it deserves.ObjectiveTo highlight the presentation of ABPA in children with asthma.MethodsThis retrospective review documents the occurrence of pediatric ABPA over a period of 31 years in one unit. Children with asthma, eosinophilia and infiltrates on chest radiograph were screened for ABPA. In these patients, demonstration of immediate hypersensitivity response against Aspergillus species along with serological profile and pulmonary function testing were done. Bronchography/computed tomography (CT) of the chest demonstrated central bronchiectasis (CB). CT of the paranasal sinuses was done in patients with upper airways symptoms. In those suspected with allergic Aspergillus sinusitis (AAS) consent was sought from the parents for the invasive procedure needed for the diagnosis of AAS.ResultsOf the 349 patients with ABPA diagnosed, 42 (12.03%) were in the pediatric age group. The mean age on presentation was 12.9 ± 4 years with a male preponderance. All patients had asthma and positive intradermal/skin prick test against Aspergillus species. Ring shadows, the most common radiological presentation, were seen in 28 of 42 patients. Bronchography/CT of the chest demonstrated CB, a feature pathognomic of ABPA, in 32 of 42 patients. High attenuation mucus plugs was observed in 7 of 36 patients while ABPA-seropositive was diagnosed in 10 of 42 patients. On imaging, sinusitis was seen in 20 of 30 patients with upper airways symptoms of whom eight had suspected AAS. Three parents consented for surgery, which confirmed the diagnosis.ConclusionThis study highlights the need to evaluate asthmatic children for ABPA as also to exclude AAS.

Therapeutic bronchoalveolar lavage with conventional treatment in allergic bronchopulmonary aspergillosis.

To establish the role of therapeutic bronchoalveolar lavage in addition to conventional treatment among two groups, with allergic bronchopulmonary aspergillosis, in terms of regression in serum IgE levels and clinical recurrence at 3 and 6 months of follow-up. Aquasi-experimental study. Department of Pulmonology, Fauji Foundation Hospital, Rawalpindi, from July 2010 to December 2013. The study was carried out on 132 patients who fulfilled the Greenberger and Patterson criteria and underwent a chest X-ray, an HRCT chest and classified radiologically as with Central Bronchiectasis (CB), High Attenuation Mucus (HAM) or Other Radiological Features (ORF). Baseline serum IgE levels were noted. All patients were given treatment including prednisolone and antifungal agent itraconazole for 4 months. Patients with ORF on HRCTchest and just received the medical treatment were labeled as conventional group. Those patients who had CB or HAM radiological features also underwent bronchoscopy with therapeutic Bronchoalveolar Lavage (BAL), labeled as BALgroup. Clinical recurrence and serum IgE levels were noted at 3 and 6 months. Values were compared using chi-square and Mann-Whitney tests respectively. Around 78 (59.1%) of patients underwent bronchoscopy with therapeutic bronchoalveolar lavage to remove the mucus plugs. The mean serum IgE levels at baseline were 3312.04 ± 2526.217 and 3486.15 ± 2528.324 IU/ml in the BAL and conventional groups respectively. There was a statistically significant reduction in the mean serum IgE levels at 3 (p < 0.00) and 6 months (p < 0.001) of follow-up in BALas compared to conventional group. There was no significant difference in the clinical recurrence rate in both the groups (p=0.078 at 3 and 0.343 at 6 months respectively). Therapeutic bronchoalveolar lavage may be a useful adjunct to treatment in patients with allergic bronchopulmonary aspergillosis, serum in terms of IgE level reduction.

High-Attenuation Mucus in Allergic Bronchopulmonary Aspergillosis

Please cite this article as: Kouzaki Y, Kanoh S, Kawana A. Mucus de alta atenuacion en aspergilosis broncopulmonar alergica. Arch Bronconeumol. 2016;52:46–47. ∗ Corresponding author. E-mail address: kanoh@ndmc.ac.jp (S. Kanoh). endobronchial metastasis from renal cell carcinoma and performed repeated fiberoptic bronchoscopy to collect biopsy specimens. Although there were no malignant cells, mucus plugs showing Charcot–Leyden crystals and Aspergillus were found. Furthermore, total and Aspergillus-specific IgE levels were elevated. Aspergillus

MRI: A New Paradigm in Imaging Evaluation of Allergic Bronchopulmonary Aspergillosis?

High-resolution CT (HRCT) scanning is the imaging modality of choice for evaluation of allergic bronchopulmonary aspergillosis (ABPA). 1 Agarwal R Allergic bronchopulmonary aspergillosis. Chest. 2009; 135: 805-826 Abstract Full Text Full Text PDF PubMed Scopus (348) Google Scholar Besides diagnosis, it has a prognostic significance. High-attenuation mucus (HAM), as defined by the visual appearance of impacted mucus within the bronchi greater than that of paraspinal muscles on CT scan, has been shown to predict relapses as well as correlate with baseline immunologic severity. 2 Agarwal R Gupta D Aggarwal AN Saxena AK Chakrabarti A Jindal SK Clinical significance of hyperattenuating mucoid impaction in allergic bronchopulmonary aspergillosis: an analysis of 155 patients. Chest. 2007; 132: 1183-1190 Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar