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Watanabe M, Hagiwara E, Shintani R, Hiramatsu Y, Ikeda S, Okuda R, Sekine A, Baba T, Komatsu S, Ogura T. Clinical characteristics of pulmonary Mycobacterium avium complex disease in patients with interstitial lung disease. J Infect Chemother 2024:S1341-321X(24)00247-2. [PMID: 39245206 DOI: 10.1016/j.jiac.2024.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/16/2024] [Accepted: 09/04/2024] [Indexed: 09/10/2024]
Abstract
OBJECTIVE Mycobacterium avium complex pulmonary disease (MAC-PD) is occasionally complicated by interstitial lung disease (ILD) in clinical practice, but clinical studies are limited. This study aims to elucidate the clinical and imaging characteristics of MAC-PD in patients with ILD. METHODS We retrospectively analyzed imaging and clinical data from medical records of 54 consecutive ILD patients diagnosed with MAC-PD from 2011 to 2021 at our institution. We compared the imaging and clinical data of these patients with 2218 ILD patients diagnosed at our institution. RESULTS The mean age of the patients was 74 years, with 25 males and 29 females, and a mean body mass index (BMI) of 20.0 kg/m2. Compared to all ILD patients, ILD-associated MAC-PD had older ages, lower BMI. The most common underlying ILD diagnosis was unclassifiable interstitial pneumonia. MAC-PD imaging classification was nodular-bronchiectatic (NB) type in 17 patients, fibro-cavitary (FC) type in 15 patients, and unclassifiable (UC) type in 22 patients. Many UC types were difficult to diagnose due to the absence of clear findings indicative of MAC infection. Chronic pulmonary aspergillosis complication was 24.1 %. The mean survival of ILD-associated MAC-PD was 55.6 months, shorter than that of regular MAC-PD. The UC type had a shorter survival than the NB type, similar to the FC type. CONCLUSION MAC-PD associated with ILD frequently complicates chronic pulmonary aspergillosis and has a poor prognosis. The most common imaging type, UC type, particularly has a shorter survival. Careful management is essential for MAC-PD associated with ILD.
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Affiliation(s)
- Masayuki Watanabe
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan.
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Ryota Shintani
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Yuri Hiramatsu
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Satoshi Ikeda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Ryo Okuda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Akimasa Sekine
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Shigeru Komatsu
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
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Tashiro M, Takazono T, Izumikawa K. Chronic pulmonary aspergillosis: comprehensive insights into epidemiology, treatment, and unresolved challenges. Ther Adv Infect Dis 2024; 11:20499361241253751. [PMID: 38899061 PMCID: PMC11186400 DOI: 10.1177/20499361241253751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/23/2024] [Indexed: 06/21/2024] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a challenging respiratory infection caused by the environmental fungus Aspergillus. CPA has a poor prognosis, with reported 1-year mortality rates ranging from 7% to 32% and 5-year mortality rates ranging from 38% to 52%. A comprehensive understanding of the pathogen, pathophysiology, risk factors, diagnosis, surgery, hemoptysis treatment, pharmacological therapy, and prognosis is essential to manage CPA effectively. In particular, Aspergillus drug resistance and cryptic species pose significant challenges. CPA lacks tissue invasion and has specific features such as aspergilloma. The most critical risk factor for the development of CPA is pulmonary cavitation. Diagnostic approaches vary by CPA subtype, with computed tomography (CT) imaging and Aspergillus IgG antibodies being key. Treatment strategies include surgery, hemoptysis management, and antifungal therapy. Surgery is the curative option. However, reported postoperative mortality rates range from 0% to 5% and complications range from 11% to 63%. Simple aspergilloma generally has a low postoperative mortality rate, making surgery the first choice. Hemoptysis, observed in 50% of CPA patients, is a significant symptom and can be life-threatening. Bronchial artery embolization achieves hemostasis in 64% to 100% of cases, but 50% experience recurrent hemoptysis. The efficacy of antifungal therapy for CPA varies, with itraconazole reported to be 43-76%, voriconazole 32-80%, posaconazole 44-61%, isavuconazole 82.7%, echinocandins 42-77%, and liposomal amphotericin B 52-73%. Combinatorial treatments such as bronchoscopic triazole administration, inhalation, or direct injection of amphotericin B at the site of infection also show efficacy. A treatment duration of more than 6 months is recommended, with better efficacy reported for periods of more than 1 year. In anticipation of improvements in CPA management, ongoing advances in basic and clinical research are expected to contribute to the future of CPA management.
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Affiliation(s)
- Masato Tashiro
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Takahiro Takazono
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
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Maruguchi N, Tanaka E, Okagaki N, Tanaka Y, Sakamoto H, Takeda A, Yamamoto R, Nakamura S, Matsumura K, Ueyama M, Ikegami N, Kaji Y, Hashimoto S, Hajiro T, Taguchi Y. Clinical Impact of Chronic Pulmonary Aspergillosis in Patients with Nontuberculous Mycobacterial Pulmonary Disease and Role of Computed Tomography in the Diagnosis. Intern Med 2023; 62:3291-3298. [PMID: 36927976 DOI: 10.2169/internalmedicine.0836-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
Abstract
Objective Chronic pulmonary aspergillosis (CPA) is an important complication of nontuberculous mycobacterial pulmonary disease (NTM-PD). However, its diagnosis is challenging, as both CPA and NTM-PD present as chronic cavitary disease. The present study evaluated the impact of CPA on the survival of patients with NTM-PD and revealed the key computed tomography findings for a prompt diagnosis. Methods We retrospectively reviewed patients newly diagnosed with NTM-PD in Tenri Hospital (Tenri City, Nara Prefecture, Japan) between January 2009 and March 2018; the patients were followed up until May 2021. Clinical and radiological characteristics were assessed, and patients with CPA were identified. Results A total of 611 patients were diagnosed with NTM-PD. Among them, 38 (6.2%), 102 (17%), and 471 (77%) patients were diagnosed with NTM-PD with CPA, cavitary NTM-PD without CPA, and non-cavitary NTM-PD without CPA, respectively. The 5-year survival rate of the NTM-PD with CPA group (42.8%; 95% confidence interval: 28.7-64.0%) was lower than that of the cavitary NTM-PD without CPA group (74.4%; 95% confidence interval: 65.4-84.6%). A multivariate analysis revealed that fungal balls and cavities with adjacent extrapleural fat were significant predictive factors for NTM-PD with CPA. Conclusion NTM-PD with CPA patients exhibited a worse prognosis than cavitary NTM-PD without CPA patients. Therefore, an unerring diagnosis of CPA is essential for managing patients with NTM-PD. Computed tomography findings, such as fungal balls and cavities with adjacent extrapleural fat, may be valuable diagnostic clues when CPA is suspected in patients with NTM-PD.
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Affiliation(s)
| | - Eisaku Tanaka
- Department of Respiratory Medicine, Tenri Hospital, Japan
| | | | - Yuma Tanaka
- Department of Respiratory Medicine, Tenri Hospital, Japan
| | | | - Atsushi Takeda
- Department of Respiratory Medicine, Tenri Hospital, Japan
| | - Ryo Yamamoto
- Department of Respiratory Medicine, Tenri Hospital, Japan
| | | | | | | | - Naoya Ikegami
- Department of Respiratory Medicine, Tenri Hospital, Japan
| | - Yusuke Kaji
- Department of Respiratory Medicine, Tenri Hospital, Japan
| | | | - Takashi Hajiro
- Department of Respiratory Medicine, Tenri Hospital, Japan
| | - Yoshio Taguchi
- Department of Respiratory Medicine, Tenri Hospital, Japan
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Fayos M, Silva JT, López-Medrano F, Aguado JM. Non-Tuberculous Mycobacteria and Aspergillus Lung Co-Infection: Systematic Review. J Clin Med 2022; 11:jcm11195619. [PMID: 36233487 PMCID: PMC9571699 DOI: 10.3390/jcm11195619] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/09/2022] [Accepted: 09/20/2022] [Indexed: 11/27/2022] Open
Abstract
Non-tuberculous mycobacteria (NTM) and Aspergillus pulmonary co-infection occurs in patients with underlying lung disease and is rarely reported. We conducted a systematic search of NTM and Aspergillus pulmonary co-infection in PubMed, EMBASE, and Cochrane Library to identify cases published from 1977 to May 2022. We included 507 articles comprising 1538 cases (only 817 patients with partial relevant clinical data). Of these, 54.3% of patients were men, with a mean age of 57.7 years. Chronic obstructive pulmonary disease (21.1%), previous diagnosis of tuberculosis (18%), and asthma (11.1%) were the most common chronic lung diseases, and corticosteroids were used in 36.8% of patients. The most frequent symptoms were cough (68.2%), dyspnea (59.1%), and hemoptysis (34.1%). The most common radiological findings were bronchiectasis (52.3%) and cavitation (40.8%). NTM and Aspergillus were treated simultaneously in 47.3% of cases, whereas NTM-targeted therapy only was performed in 23.4% and Aspergillus only in 1.6%. The remaining 27.7% did not receive any treatment and were considered to be colonized. The global mortality rate was 43% (159/370). There was an increased prevalence of NTM and pulmonary aspergillosis among patients with underlying chronic lung diseases, which led to severe pulmonary affection with a poor global prognosis.
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Affiliation(s)
- Marina Fayos
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital 12 de Octubre, 28041 Madrid, Spain
- Instituto de Investigación Hospital 12 de Octubre (Imas12), 28041 Madrid, Spain
| | - Jose Tiago Silva
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital 12 de Octubre, 28041 Madrid, Spain
- Instituto de Investigación Hospital 12 de Octubre (Imas12), 28041 Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital 12 de Octubre, 28041 Madrid, Spain
- Instituto de Investigación Hospital 12 de Octubre (Imas12), 28041 Madrid, Spain
- Centro de Investigación Biomédica en Red CIBERINFEC, ISCIII, 28029 Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital 12 de Octubre, 28041 Madrid, Spain
- Instituto de Investigación Hospital 12 de Octubre (Imas12), 28041 Madrid, Spain
- Centro de Investigación Biomédica en Red CIBERINFEC, ISCIII, 28029 Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, 28040 Madrid, Spain
- Correspondence:
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Yamakawa H, Nishizawa T, Ohta H, Tsukahara Y, Nakamura T, Sato S, Kawabe R, Oba T, Akasaka K, Amano M, Kuwano K, Sasaki H, Matsushima H. Patient background and prognosis of chronic pulmonary aspergillosis in fibrosing interstitial lung disease. Medicine (Baltimore) 2022; 101:e29936. [PMID: 35960067 PMCID: PMC9371541 DOI: 10.1097/md.0000000000029936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Several previous reports have shown interstitial lung disease (ILD) to be a predictor of poor prognosis in patients with chronic pulmonary aspergillosis (CPA). However, there is a lack of clarity regarding patient background and the prognostic factors in CPA associated with ILD (CPA-ILD). Therefore, we assessed these points to obtain valuable information for clinical practice. We retrospectively surveyed and collected data from 459 patients who had serum examination for anti-Aspergillus antibody. Of these patients, we extracted and investigated CPA-ILD patients. We ultimately analyzed 32 CPA-ILD patients. Patient background factors more frequently showed the patients to be older (mean: 74.9 years), male (75.0%), and to have a smoking history (71.9%). Median survival time from the diagnosis of ILD was 76.0 months, whereas that from the diagnosis of CPA-ILD was 25.5 months. No significant differences in survival were found in regard to each ILD pattern and the presence of idiopathic pulmonary fibrosis. A higher level of C-reactive protein was a significant predictor of mortality by Cox regression analysis. CPA complicating ILD is associated with poor prognosis. ILD patients with older age, male sex, and smoking history should be aware of the potential for the development of CPA in ILD. If such patients have elevated markers of inflammation, prompt induction of antifungal treatment may improve their prognosis. Clinicians should be aware of which complications of CPA may lead to a poor prognosis for any ILD not just those limited to idiopathic pulmonary fibrosis or usual interstitial pneumonia pattern.
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Affiliation(s)
- Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, Tokyo, Japan
- *Correspondence: Hideaki Yamakawa, MD, PhD, Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama 330-0081, Japan (e-mail: )
| | - Tomotaka Nishizawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Hiroki Ohta
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Yuta Tsukahara
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Tomohiko Nakamura
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Shintaro Sato
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Rie Kawabe
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Tomohiro Oba
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Keiichi Akasaka
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Masako Amano
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Kazuyoshi Kuwano
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, Tokyo, Japan
| | - Hiroki Sasaki
- Department of Radiology, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Hidekazu Matsushima
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
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Impact of emphysema on the prognosis of Mycobacterium avium complex pulmonary disease. Respir Med 2022; 192:106738. [PMID: 35051876 DOI: 10.1016/j.rmed.2022.106738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/10/2021] [Accepted: 01/07/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a major comorbid disease of Mycobacterium avium complex pulmonary disease (MAC-PD). Emphysema is one of the main pathological findings in COPD, a risk factor for chronic pulmonary aspergillosis (CPA), and is associated with poor prognosis. We aimed to clarify the effect of emphysema on mortality in MAC-PD. METHODS We retrospectively analyzed 203 patients with MAC-PD at The Jikei Daisan Hospital between January 2014 and December 2018. We investigated the mortality and CPA development rates after MAC-PD diagnosis in patients with or without emphysema. RESULTS Multivariate Cox proportional hazards regression analysis showed the following negative prognostic factors in patients with MAC-PD: emphysema (hazard ratio [HR]: 11.46; 95% confidence interval [CI]: 1.30-100.90; P = 0.028); cavities (HR: 3.12; 95% CI: 1.22-7.94; P = 0.017); and low body mass index (<18.5 kg/m2) (HR: 4.62; 95% CI: 1.63-13.11; P = 0.004). The mortality and occurrence of CPA were higher in MAC-PD patients with than without emphysema (log-rank test, P < 0.0001 and P < 0.0001). CONCLUSION Our study findings showed that emphysema detected by computed tomography was associated with an increased risk of CPA development and mortality in MAC-PD.
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Kimura Y, Sasaki Y, Suzuki J, Suzuki J, Igei H, Suzukawa M, Matsui H. Prognostic factors of chronic pulmonary aspergillosis: A retrospective cohort of 264 patients from Japan. PLoS One 2021; 16:e0249455. [PMID: 33793645 PMCID: PMC8016288 DOI: 10.1371/journal.pone.0249455] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/18/2021] [Indexed: 11/18/2022] Open
Abstract
Background Chronic pulmonary aspergillosis (CPA) develops in various underlying pulmonary conditions. There is scarce data evaluating interstitial lung disease (ILD)/abnormalities (ILA) as such conditions, and it has not been explored much whether non-tuberculous mycobacterial pulmonary disease (NTM-PD) is a prognostic factor for mortality in CPA patients. Few reports had investigated prognostic factors of CPA including underlying pulmonary conditions. Objectives To explore prognostic factors of CPA including pulmonary conditions. Methods We conducted a retrospective cohort study of 264 CPA patients from a center for pulmonary aspergillosis in Japan. Results Survival rates were 78.7%, 61.0%, and 47.4% at 1, 3, and 5 years, respectively. Of 264 patients, 53 (20.1%) and 87 (33.1%) were complicated with ILA and NTM-PD. Several independent prognostic factors were identified by multivariate Cox proportional analysis: ILA (HR 1.76, 95%CI 1.06–2.92, p = 0.029), age (1.05, 1.02–1.08, p<0.001), male sex (2.48, 1.34–4.59, p = 0.004), body mass index of <18.5 kg/m2 (1,87, 1.20–2.90, p = 0.005), presence of aspergilloma (1.59, 1.04–2.45, p = 0.033), and lower serum albumin (0.56, 0.38–0.83, p = 0.004). NTM-PD was not associated with higher mortality (0.85, 0.52–1.38, p = 0.51). Conclusions The poor prognosis of CPA and several prognostic factors were revealed. Early diagnosis and intervention is required with reference to such factors.
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Affiliation(s)
- Yuya Kimura
- Center for Pulmonary Diseases, Department of Respiratory Medicine, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
- * E-mail:
| | - Yuka Sasaki
- Center for Pulmonary Diseases, Department of Respiratory Medicine, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Junko Suzuki
- Center for Pulmonary Diseases, Department of Respiratory Medicine, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Jun Suzuki
- Center for Pulmonary Diseases, Department of Respiratory Medicine, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Hiroshi Igei
- Center for Pulmonary Diseases, Department of Respiratory Medicine, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Maho Suzukawa
- Center for Pulmonary Diseases, Department of Respiratory Medicine, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Hirotoshi Matsui
- Center for Pulmonary Diseases, Department of Respiratory Medicine, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
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Phoompoung P, Chayakulkeeree M. Chronic Pulmonary Aspergillosis Following Nontuberculous Mycobacterial Infections: An Emerging Disease. J Fungi (Basel) 2020; 6:jof6040346. [PMID: 33302348 PMCID: PMC7762599 DOI: 10.3390/jof6040346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/25/2020] [Accepted: 12/04/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic pulmonary aspergillosis (CPA) following nontuberculous mycobacterial (NTM) lung disease is being increasingly recognized, especially in countries where tuberculosis is not endemic, with an incidence rate of 3.9–16.7%. NTM lung disease has been identified as a predictor of mortality in CPA patients. The major risk factors for NTM-associated CPA include fibrocavitary NTM lung disease, the presence of pulmonary emphysema, and high-dose corticosteroid use. The onset of CPA is 1.5–7 years following the diagnosis of NTM lung disease. The diagnosis can be made using standard criteria; however, serological diagnosis using Aspergillus precipitin has demonstrated a higher sensitivity and specificity when compared with fungal culture from respiratory specimens. Treatment is challenging since rifampicin and oral triazoles should not be used concomitantly. The prognosis is poor, and the factors associated with worse prognosis are corticosteroid use and high C-reactive protein level.
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Impact of Aspergillus precipitating antibody test results on clinical outcomes of patients with Mycobacterium avium complex lung disease. Respir Med 2020; 166:105955. [DOI: 10.1016/j.rmed.2020.105955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/17/2020] [Accepted: 03/31/2020] [Indexed: 01/19/2023]
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