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Simmonds NJ, Southern KW, De Wachter E, De Boeck K, Bodewes F, Mainz JG, Middleton PG, Schwarz C, Vloeberghs V, Wilschanski M, Bourrat E, Chalmers JD, Ooi CY, Debray D, Downey DG, Eschenhagen P, Girodon E, Hickman G, Koitschev A, Nazareth D, Nick JA, Peckham D, VanDevanter D, Raynal C, Scheers I, Waller MD, Sermet-Gaudelus I, Castellani C. ECFS standards of care on CFTR-related disorders: Identification and care of the disorders. J Cyst Fibros 2024; 23:590-602. [PMID: 38508949 DOI: 10.1016/j.jcf.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/06/2024] [Accepted: 03/08/2024] [Indexed: 03/22/2024]
Abstract
This is the third paper in the series providing updated information and recommendations for people with cystic fibrosis transmembrane conductance regulator (CFTR)-related disorder (CFTR-RD). This paper covers the individual disorders, including the established conditions - congenital absence of the vas deferens (CAVD), diffuse bronchiectasis and chronic or acute recurrent pancreatitis - and also other conditions which might be considered a CFTR-RD, including allergic bronchopulmonary aspergillosis, chronic rhinosinusitis, primary sclerosing cholangitis and aquagenic wrinkling. The CFTR functional and genetic evidence in support of the condition being a CFTR-RD are discussed and guidance for reaching the diagnosis, including alternative conditions to consider and management recommendations, is provided. Gaps in our knowledge, particularly of the emerging conditions, and future areas of research, including the role of CFTR modulators, are highlighted.
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Affiliation(s)
- N J Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, UK.
| | - K W Southern
- Department of Women's and Children's Health, University of Liverpool, University of Liverpool, Alder Hey Children's Hospital, Liverpool, UK
| | - E De Wachter
- Cystic Fibrosis Center, Pediatric Pulmonology department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - K De Boeck
- Department of Pediatrics, University of Leuven, Leuven, Belgium
| | - F Bodewes
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Groningen Medical Center, Groningen, the Netherlands
| | - J G Mainz
- Cystic Fibrosis Center, Brandenburg Medical School (MHB), University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - P G Middleton
- Cystic Fibrosis and Bronchiectasis Service, Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, News South Wales, Australia
| | - C Schwarz
- HMU-Health and Medical University Potsdam, CF Center Westbrandenburg, Campus Potsdam, Germany
| | - V Vloeberghs
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - M Wilschanski
- CF Center, Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - E Bourrat
- APHP, Service de Dermatologie, CRMR MAGEC Nord St Louis, Hôpital-Saint Louis, Paris, France
| | - J D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - C Y Ooi
- a) School of Clinical Medicine, Discipline of Paediatrics and Child Health, Medicine & Health, University of New South Wales, Level 8, Centre for Child Health Research & Innovation Bright Alliance Building Cnr Avoca & High Streets, Randwick, Sydney, NSW, Australia, 2031; b) Sydney Children's Hospital, Gastroenterology Department, High Street, Randwick, Sydney, NSW, Australia, 2031
| | - D Debray
- Pediatric Hepatology unit, Centre de Référence Maladies Rares (CRMR) de l'atrésie des voies biliaires et cholestases génétiques (AVB-CG), National network for rare liver diseases (Filfoie), ERN rare liver, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - D G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | - E Girodon
- Service de Médecine Génomique des Maladies de Système et d'Organe, APHP.Centre - Université de Paris Cité, Hôpital Cochin, Paris, France
| | - G Hickman
- APHP, Service de Dermatologie, CRMR MAGEC Nord St Louis, Hôpital-Saint Louis, Paris, France
| | - A Koitschev
- Klinikum Stuttgart, Pediatric Otorhinolaryngology, Stuttgart, Germany
| | - D Nazareth
- a) Adult CF Unit, Liverpool Heart and Chest Hospital NHS Foundation Trust, U.K; b) Clinical Infection, Microbiology and Immunology, University of Liverpool, UK
| | - J A Nick
- Department of Medicine, National Jewish Health, Denver, CO, 80206, USA, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - D Peckham
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - D VanDevanter
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - C Raynal
- Laboratory of molecular genetics, University Hospital of Montpellier and INSERM U1046 PHYMEDEXP, Montpellier, France
| | - I Scheers
- Department of Pediatrics, Pediatric Gastroenterology and Hepatology Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - M D Waller
- Adult Cystic Fibrosis and Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; Honorary Senior Lecturer, King's College London, London, United Kingdom
| | - I Sermet-Gaudelus
- INSERM U1151, Institut Necker Enfants Malades, Paris, France; Université de Paris, Paris, France; Centre de référence Maladies Rares, Mucoviscidose et maladies apparentées, Hôpital Necker Enfants malades, Paris, France
| | - C Castellani
- IRCCS Istituto Giannina Gaslini, Cystic Fibrosis Center, Genoa, Italy
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Jansen AME, Eggermont MN, Wilms EB, Aziz S, Reijers M, Roukema J, Warris A, Brüggemann RJM, van der Meer R. Evaluation of the drug-drug interaction between triazole antifungals and cystic fibrosis transmembrane conductance regulator modulators in a real-life cohort. Med Mycol 2024; 62:myae020. [PMID: 38444173 PMCID: PMC10956399 DOI: 10.1093/mmy/myae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/05/2024] [Accepted: 03/04/2024] [Indexed: 03/07/2024] Open
Abstract
Limited data on the clinical management of drug-drug interactions between triazoles and Cystic Fibrosis transmembrane conductance regulator (CFTR) modulators are available. We retrospectively evaluated azole target attainment and dose adaptations in patients from two Dutch CF centres concomitantly receiving triazoles and CFTR modulators. In total, 21 patients with 59 triazole trough concentrations were evaluated. Subtherapeutic concentrations were frequently observed, especially for itraconazole and voriconazole. Of the investigated antifungal agents, posaconazole appears the most preferable option. Our results emphasize the importance of adequate management of this interaction and underpin the added value of therapeutic drug monitoring of triazoles in this population.
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Affiliation(s)
- Anouk M E Jansen
- Department of Pharmacy, Radboud university medical center, Radboud Institute for Medical Innovations, Nijmegen, the Netherlands
- Radboud university medical center-Canisius Wilhelmina Ziekenhuis Center of Expertise for Mycology, Nijmegen, The Netherlands
| | - Margot N Eggermont
- Department of Pulmonology and Adult CF Centre, Haga Teaching Hospital, The Hague, Netherlands
| | - Erik B Wilms
- Apotheek Haagse Ziekenhuizen (AHZ) and Department of Pharmacy, Haga Teaching Hospital, The Hague, Netherlands
| | - Sami Aziz
- Department of Pharmacy, Radboud university medical center, Radboud Institute for Medical Innovations, Nijmegen, the Netherlands
| | - Monique Reijers
- Department of Pulmonology, Radboud university medical center, Radboud Institute for Medical Innovations, Nijmegen, the Netherlands
| | - Jolt Roukema
- Department of Paediatrics, Radboud university medical center, Amalia Children's Hospital, Radboud Institute for Medical Innovations, Nijmegen, the Netherlands
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud university medical center, Radboud Institute for Medical Innovations, Nijmegen, the Netherlands
- Radboud university medical center-Canisius Wilhelmina Ziekenhuis Center of Expertise for Mycology, Nijmegen, The Netherlands
| | - Renske van der Meer
- Department of Pulmonology and Adult CF Centre, Haga Teaching Hospital, The Hague, Netherlands
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Bradbury JD, Chesshyre E, Orenti A, Jung A, Warris A. A multinational report on SARS-CoV-2 infection outcomes in people with CF and Aspergillus infection or ABPA. J Cyst Fibros 2024; 23:354-363. [PMID: 37925255 DOI: 10.1016/j.jcf.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/01/2023] [Accepted: 10/28/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Aspergillus infection is known to be associated with worse respiratory outcomes in people with CF (pwCF) and is a well-recognised complication of severe SARS-CoV-2 infection. The aim of this observational cross-sectional study was to examine the association of pre-existing Aspergillus infection and/or allergic bronchopulmonary aspergillosis (ABPA) in pwCF and severity of COVID-19. METHODS Data on SARS-CoV-2 infections in pwCF from January 2020 to June 2021 were collected by the European Cystic Fibrosis Society Patient Registry. The primary outcome was COVID-19 severity measured by hospitalisation comparing those with Aspergillus infection and/or ABPA in the 12 months preceding COVID-19 and those without. RESULTS In total, 1095 pwCF were diagnosed with SARS-CoV-2 and information on pre-existing Aspergillus/ABPA status was available from 807. PwCF and SARS-CoV-2 in the Aspergillus/ABPA group (n = 153), in comparison to the non-Aspergillus/ABPA group (n = 654), were more likely to be hospitalised (adjusted OR 1.79 (1.19 to 2.85); p = 0.005) and their disease course was more likely to be complicated by sepsis (adjusted OR 7.78 (1.78 to 49.43); p = 0.008). The association with hospital admission was no longer significant after excluding patients with ABPA. Secondary analysis comparing pwCF who received antifungal treatment (n = 18), versus those who did not (n = 474) during COVID-19, showed a higher rate of hospitalisation (p < 0.001); intensive care unit admission (p < 0.001), and requirement for invasive ventilation (p < 0.001) in the antifungal treated group. CONCLUSION We show that pre-existing Aspergillus/ABPA is associated with increased rates of hospitalisation and sepsis during COVID-19 in pwCF.
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Affiliation(s)
- Jacob D Bradbury
- MRC Centre for Medical Mycology, University of Exeter, EX4 4QD, UK; Department of Pharmacology, University of Oxford, OX1 3QT, UK
| | - Emily Chesshyre
- MRC Centre for Medical Mycology, University of Exeter, EX4 4QD, UK; Department of Paediatrics, Royal Devon University Healthcare NHS Foundation Trust, EX2 5DW, UK
| | - Annalisa Orenti
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Biometry and Epidemiology G.A. Maccacaro, University of Milan, Milan 20122, Italy
| | - Andreas Jung
- Paediatric Pulmonology, University Children's Hospital Zurich, Ramistrasse 102, Stadtkreis 7 8006, Zurich, Switzerland
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, EX4 4QD, UK; Department of Paediatric Infectious Diseases, Great Ormond Street Hospital, London, WC1N 3JH, UK
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Benlala I, Klaar R, Gaass T, Macey J, Bui S, Senneville BDD, Berger P, Laurent F, Dournes G, Dinkel J. Non-Contrast-Enhanced Functional Lung MRI to Evaluate Treatment Response of Allergic Bronchopulmonary Aspergillosis in Patients With Cystic Fibrosis: A Pilot Study. J Magn Reson Imaging 2024; 59:909-919. [PMID: 37265441 DOI: 10.1002/jmri.28844] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) in cystic fibrosis (CF) patients is associated with severe lung damage and requires specific therapeutic management. Repeated imaging is recommended to both diagnose and follow-up response to treatment of ABPA in CF. However, high risk of cumulative radiation exposure requires evaluation of free-radiation techniques in the follow-up of CF patients with ABPA. PURPOSE To evaluate whether Fourier decomposition (FD) functional lung MRI can detect response to treatment of ABPA in CF patients. STUDY TYPE Retrospective longitudinal. POPULATION Twelve patients (7M, median-age:14 years) with CF and ABPA with pre- and post-treatment MRI. FIELD STRENGTH/SEQUENCE 2D-balanced-steady-state free-precession (bSSFP) sequence with FD at 1.5T. ASSESSMENT Ventilation-weighted (V) and perfusion-weighted (Q) maps were obtained after FD processing of 2D-coronal bSSFP time-resolved images acquired before and 3-9 months after treatment. Defects extent was assessed on the functional maps using a qualitative semi-quantitative score (0 = absence/negligible, 1 = <50%, 2 = >50%). Mean and coefficient of variation (CV) of the ventilation signal-intensity (VSI) and the perfusion signal-intensity (QSI) were calculated. Measurements were performed independently by three readers and averaged. Inter-reader reproducibility of the measurements was assessed. Pulmonary function tests (PFTs) were performed within 1 week of both MRI studies as markers of the airflow-limitation severity. STATISTICAL TESTS Comparisons of medians were performed using the paired Wilcoxon-test. Reproducibility was assessed using intraclass correlation coefficient (ICC). Correlations between MRI and PFT parameters were assessed using the Spearman-test (rho correlation-coefficient). A P-value <0.05 was considered as significant. RESULTS Defects extent on both V and Q maps showed a significant reduction after ABPA treatment (4.25 vs. 1.92 for V-defect-score and 5 vs. 2.75 for Q-defect-score). VSI_mean was significantly increased after treatment (280 vs. 167). Qualitative analyses reproducibility showed an ICC > 0.90, while the ICCs of the quantitative measurements was almost perfect (>0.99). Changes in VSI_cv and QSI_cv before and after treatment correlated inversely with changes of FEV1%p (rho = -0.68 for both). DATA CONCLUSION Non-contrast-enhanced FD lung MRI has potential to reproducibly assess response to treatment of ABPA in CF patients and correlates with PFT obstructive parameters. EVIDENCE LEVEL 4 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Ilyes Benlala
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
- Univ. Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
- CHU Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, Service d'Exploration Fonctionnelle Respiratoire, Unité de Pneumologie Pédiatrique, CIC 1401, Pessac, France
- INSERM, U1045, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
| | - Rabea Klaar
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Thomas Gaass
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Julie Macey
- CHU Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, Service d'Exploration Fonctionnelle Respiratoire, Unité de Pneumologie Pédiatrique, CIC 1401, Pessac, France
| | - Stéphanie Bui
- CHU Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, Service d'Exploration Fonctionnelle Respiratoire, Unité de Pneumologie Pédiatrique, CIC 1401, Pessac, France
| | | | - Patrick Berger
- Univ. Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
- CHU Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, Service d'Exploration Fonctionnelle Respiratoire, Unité de Pneumologie Pédiatrique, CIC 1401, Pessac, France
| | - François Laurent
- Univ. Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
- CHU Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, Service d'Exploration Fonctionnelle Respiratoire, Unité de Pneumologie Pédiatrique, CIC 1401, Pessac, France
| | - Gael Dournes
- Univ. Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, Pessac, France
- CHU Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, Service d'Exploration Fonctionnelle Respiratoire, Unité de Pneumologie Pédiatrique, CIC 1401, Pessac, France
| | - Julien Dinkel
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
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Balu N, Pipavath S. Editorial for "Non-Contrast-Enhanced Functional Lung MRI to Evaluate Treatment Response of Allergic Bronchopulmonary Aspergillosis in Patients With Cystic Fibrosis: A Pilot Study". J Magn Reson Imaging 2024; 59:920-921. [PMID: 37285083 DOI: 10.1002/jmri.28845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 06/08/2023] Open
Affiliation(s)
- Niranjan Balu
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Sudhakar Pipavath
- Department of Radiology, University of Washington, Seattle, Washington, USA
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Laurent F, Benlala I, Dournes G. Radiological Diagnosis of Pulmonary Aspergillosis. Semin Respir Crit Care Med 2024; 45:50-60. [PMID: 38286137 DOI: 10.1055/s-0043-1776998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Imaging plays an important role in the various forms of Aspergillus-related pulmonary disease. Depending on the immune status of the patient, three forms are described with distinct imaging characteristics: invasive aspergillosis affecting severely immunocompromised patients, chronic pulmonary aspergillosis affecting less severely immunocompromised patients but suffering from a pre-existing structural lung disease, and allergic bronchopulmonary aspergillosis related to respiratory exposure to Aspergillus species in patients with asthma and cystic fibrosis. Computed tomography (CT) has been demonstrated more sensitive and specific than chest radiographs and its use has largely contributed to the diagnosis, follow-up, and evaluation of treatment in each condition. In the last few decades, CT has also been described in the specific context of cystic fibrosis. In this particular clinical setting, magnetic resonance imaging and the recent developments in artificial intelligence have shown promising results.
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Affiliation(s)
- François Laurent
- Centre de Recherche Cardio-thoracique de Bordeaux, University of Bordeaux, Pessac, France
| | - Ilyes Benlala
- Centre de Recherche Cardio-thoracique de Bordeaux, University of Bordeaux, Pessac, France
- CHU Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Centre de Recherche Cardio-thoracique de Bordeaux, University of Bordeaux, Pessac, France
| | - Gael Dournes
- Centre de Recherche Cardio-thoracique de Bordeaux, University of Bordeaux, Pessac, France
- CHU Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Centre de Recherche Cardio-thoracique de Bordeaux, University of Bordeaux, Pessac, France
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De Francesco MA. Drug-Resistant Aspergillus spp.: A Literature Review of Its Resistance Mechanisms and Its Prevalence in Europe. Pathogens 2023; 12:1305. [PMID: 38003770 PMCID: PMC10674884 DOI: 10.3390/pathogens12111305] [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: 10/13/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
Infections due to the Aspergillus species constitute an important challenge for human health. Invasive aspergillosis represents a life-threatening disease, mostly in patients with immune defects. Drugs used for fungal infections comprise amphotericin B, triazoles, and echinocandins. However, in the last decade, an increased emergence of azole-resistant Aspergillus strains has been reported, principally belonging to Aspergillus fumigatus species. Therefore, both the early diagnosis of aspergillosis and its epidemiological surveillance are very important to establish the correct antifungal therapy and to ensure a successful patient outcome. In this paper, a literature review is performed to analyze the prevalence of Aspergillus antifungal resistance in European countries. Amphotericin B resistance is observed in 2.6% and 10.8% of Aspergillus fumigatus isolates in Denmark and Greece, respectively. A prevalence of 84% of amphotericin B-resistant Aspergillus flavus isolates is reported in France, followed by 49.4%, 35.1%, 21.7%, and 20% in Spain, Portugal, Greece, and amphotericin B resistance of Aspergillus niger isolates is observed in Greece and Belgium with a prevalence of 75% and 12.8%, respectively. The prevalence of triazole resistance of Aspergillus fumigatus isolates, the most studied mold obtained from the included studies, is 0.3% in Austria, 1% in Greece, 1.2% in Switzerland, 2.1% in France, 3.9% in Portugal, 4.9% in Italy, 5.3% in Germany, 6.1% in Denmark, 7.4% in Spain, 8.3% in Belgium, 11% in the Netherlands, and 13.2% in the United Kingdom. The mechanism of resistance is mainly driven by the TR34/L98H mutation. In Europe, no in vivo resistance is reported for echinocandins. Future studies are needed to implement the knowledge on the spread of drug-resistant Aspergillus spp. with the aim of defining optimal treatment strategies.
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Affiliation(s)
- Maria Antonia De Francesco
- Department of Molecular and Translational Medicine, Institute of Microbiology, University of Brescia, ASST Spedali Civili, 25123 Brescia, Italy
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Roboubi A, Audousset C, Fréalle É, Brun AL, Laurent F, Vitte J, Mortuaire G, Lefevre G, Cadranel J, Chenivesse C. Allergic bronchopulmonary aspergillosis: A multidisciplinary review. J Mycol Med 2023; 33:101392. [PMID: 37172543 DOI: 10.1016/j.mycmed.2023.101392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a rare disease characterized by a complex allergic inflammatory reaction of airways against Aspergillus affecting patients with chronic respiratory diseases (asthma, cystic fibrosis). Exacerbation is often the way to diagnose ABPA and marks its evolution by its recurrent character leading to cortico-requirement or long-term antifungal treatment. Early diagnosis allows treatment of ABPA at an initial stage, preventing recurrence of exacerbations and long-term complications, mainly represented by bronchiectasis. This review of the literature aims to present the current state of the art in terms of diagnosis and treatment of ABPA from a multidisciplinary perspective. As there is no clinical, biological nor radiological specific sign, diagnostic criteria are regularly revised. They are mainly based on the elevation of total and specific IgE against Aspergillus fumigatus and the presence of suggestive CT abnormalities such as mucoid impaction and consolidations. ABPA management includes eviction of mold and pharmacological therapy. Exacerbations are treated in first line with a moderate dose of oral corticosteroids. Azole antifungal agents represent an alternative for the treatment of exacerbations and are the preferential strategy to reduce the future risk of exacerbations and for corticosteroids sparing. Asthma biologics may be of interest; however, their place remains to be determined. Avoiding complications of ABPA while limiting the side effects of systemic drugs remains a major challenge of ABPA management. Several drugs, including new antifungals and asthma biologics, are currently being tested and may be useful in the future.
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Affiliation(s)
| | - Camille Audousset
- CHU Lille, Univ. Lille, CNRS, Inserm, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, Lille, France
| | - Émilie Fréalle
- CHU Lille, Laboratoire de Parasitologie-Mycologie, Univ. Lille, ULR 4515-LGCgE, Laboratoire de Génie Civil et Géo-Environnement, Lille F-59000, France
| | - Anne-Laure Brun
- Hôpital Foch, Service de radiologie diagnostique et interventionnelle, Suresnes, France
| | - François Laurent
- Université de Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, INSERM U1045, CIC1401, CHU de Bordeaux, Pessac, France
| | - Joana Vitte
- Aix-Marseille Univ, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France; Desbrest Institute of Epidemiology and Public Health IDESP, Univ Montpellier, INSERM UA 11, Montpellier, France
| | - Geoffrey Mortuaire
- CHU de Lille, Service d'ORL et de chirurgie cervico-faciale, Lille 59000, France; Université de Lille, Inserm, CHU de Lille, U1286, INFINITE-Institute for translational research in inflammation, Lille 59000, France
| | - Guillaume Lefevre
- Univ Lille, U1286 INFINITE - Lille Inflammation Research International Center, CHU Lille, Lille, France
| | - Jacques Cadranel
- Sorbonne Université, APHP-Hopital Tenon, GRC04 Theranoscan Sorbonne Université, Paris, France
| | - Cécile Chenivesse
- Univ. Lille, CHU Lille, CNRS, Inserm, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, Lille, France; CRISALIS (Clinical Research Initiative in Severe Asthma: a Lever for Innovation & Science), F-CRIN Network, INSERM US015, Toulouse, France.
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Cottin V. Eosinophilic Lung Diseases. Immunol Allergy Clin North Am 2023; 43:289-322. [PMID: 37055090 DOI: 10.1016/j.iac.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
The eosinophilic lung diseases may manifest as chronic eosinophilic pneumonia, acute eosinophilic pneumonia, or as the Löffler syndrome (generally of parasitic etiology). The diagnosis of eosinophilic pneumonia is made when both characteristic clinical-imaging features and alveolar eosinophilia are present. Peripheral blood eosinophils are generally markedly elevated; however, eosinophilia may be absent at presentation. Lung biopsy is not indicated except in atypical cases after multidisciplinary discussion. The inquiry to possible causes (medications, toxic drugs, exposures, and infections especially parasitic) must be meticulous. Idiopathic acute eosinophilic pneumonia may be misdiagnosed as infectious pneumonia. Extrathoracic manifestations raise the suspicion of a systemic disease especially eosinophilic granulomatosis with polyangiitis. Airflow obstruction is frequent in allergic bronchopulmonary aspergillosis, idiopathic chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis, and hypereosinophilic obliterative bronchiolitis. Corticosteroids are the cornerstone of therapy, but relapses are common. Therapies targeting interleukin 5/interleukin-5 are increasingly used in eosinophilic lung diseases.
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Affiliation(s)
- Vincent Cottin
- Service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Centre de référence coordonnateur des maladies pulmonaires rares (OrphaLung), 28 Avenue Doyen Lepine, Lyon Cedex 69677, France; Université Lyon 1, INRAE, UMR754, Lyon, France.
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10
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Abstract
In cystic fibrosis, a new era has started with the approval and use of highly effective cystic fibrosis transport regulator (CFTR) modulator therapy. As pulmonary function is increasing and exacerbation rate significantly decreases, the current meaning of fungal pulmonary diseases is questioned. During the past couple of decades, several studies have been conducted regarding fungal colonization and infection of the airways in people with cystic fibrosis. Although Aspergillus fumigatus for filamentous fungi and Candida albicans for yeasts remain by far the most common fungal species in patients with cystic fibrosis, the pattern of fungal species associated with cystic fibrosis has considerably diversified recently. Fungi such as Scedosporium apiospermum or Exophiala dermatitidis are recognized as pathogenic in cystic fibrosis and therefore need attention in clinical settings. In this article, current definitions are stated. Important diagnostic steps are described, and their usefulness discussed. Furthermore, clinical treatment strategies and recommendations are named and evaluated. In cystic fibrosis, fungal entities can be divided into different subgroups. Besides colonization, allergic bronchopulmonary aspergillosis, bronchitis, sensitization, pneumonia, and aspergilloma can occur as a fungal disease entity. For allergic bronchopulmonary aspergillosis, bronchitis, pneumonia, and aspergilloma, clear indications for therapy exist but this is not the case for sensitization or colonization. Different pulmonary fungal disease entities in people with cystic fibrosis will continue to occur also in an era of highly effective CFTR modulator therapy. Whether the percentage will decrease or not will be the task of future evaluations in studies and registry analysis. Using the established definition for different categories of fungal diseases is recommended and should be taken into account if patients are deteriorating without responding to antibiotic treatment. Drug-drug interactions, in particular when using azoles, should be recognized and therapies need to be adjusted accordingly.
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Affiliation(s)
- Carsten Schwarz
- Department of Education and Research, Health and Medical University-Health and Medical University Potsdam, Potsdam, Germany.,Division of Cystic Fibrosis, Cystic Fibrosis Center West Brandenburg, Postdam, Germany
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11
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Steels S, Proesmans M, Bossuyt X, Dupont L, Frans G. Laboratory biomarkers in the diagnosis and follow-up of treatment of allergic bronchopulmonary aspergillosis in cystic fibrosis. Crit Rev Clin Lab Sci 2023; 60:1-24. [PMID: 35968577 DOI: 10.1080/10408363.2022.2101612] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA), a severe inflammatory respiratory disease, is caused by a hypersensitivity reaction to the colonization of the airways with Aspergillus fumigatus. It is most often described in patients with asthma or cystic fibrosis. The diagnosis of ABPA is based on a combination of clinical, radiological, and immunological findings that have been included in different diagnostic criteria over the years. In this paper, we review the biomarkers included in these diagnostic criteria and novel research biomarkers that may be used in the diagnosis and treatment follow-up of ABPA in cystic fibrosis.
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Affiliation(s)
- Sophie Steels
- Department of Laboratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marijke Proesmans
- Department of Pediatrics, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Xavier Bossuyt
- Department of Laboratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Clinical and Diagnostic Immunology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Lieven Dupont
- Department of Respiratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Glynis Frans
- Department of Laboratory Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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12
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The value of bronchocele attenuation in pulmonary computed tomography in assessment of allergic bronchopulmonary aspergillosis in the background of cystic fibrosis: A cross-sectional study. Ann Med Surg (Lond) 2022; 84:104892. [DOI: 10.1016/j.amsu.2022.104892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/01/2022] [Accepted: 10/30/2022] [Indexed: 11/18/2022] Open
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13
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Clinical Impact of Aspergillus fumigatus in Children with Cystic Fibrosis. Microorganisms 2022; 10:microorganisms10040739. [PMID: 35456789 PMCID: PMC9032721 DOI: 10.3390/microorganisms10040739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background. The clinical relevance of Aspergillus fumigatus (Af) in cystic fibrosis (CF) is controversial. The aims of the study were to assess the prevalence of Af disease in our cohort of CF patients and evaluate whether allergic bronchopulmonary aspergillosis (ABPA) and sensitization to Af affected lung function, body mass index (BMI) and exacerbations. Methods. Clinical data and lung function of CF patients aged 6−18 years followed at the CF Centre of Parma (Italy) were recorded. Patients were classified as: patients with no signs of Af, patients sensitized or colonized by Af, patients with ABPA or patients with Aspergillus bronchitis (Ab). Results. Of 38 CF patients (14.2 years (6.2−18.8) M 23), 8 (21%) showed Af sensitization, 7 (18.4%) showed ABPA, 1 (2.6%) showed Af colonization and 1 (2.6%) showed Ab. Compared to non-ABPA, patients with ABPA had lower BMI (15.9 ± 1.6 vs. 19.7 ± 3.4, p < 0.005), lower lung function (FEV1 61.5 ± 25.9% vs. 92.3 ± 19.3%, p < 0.001) and more exacerbations/year (4.43 ± 2.44 vs. 1.74 ± 2.33, p < 0.005). Patients with Af sensitization showed more exacerbations/year than non-Af patients (3.5 ± 3.2 vs. 0.9 ± 1.2, p < 0.005). ABPA and sensitized patients had more abnormalities on chest CT scans. Conclusion. This study showed the relevant clinical impact of ABPA and Af sensitization in terms of exacerbations and lung structural damage.
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14
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Agarwal R, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Aggarwal AN. Allergic Bronchopulmonary Aspergillosis. Clin Chest Med 2022; 43:99-125. [DOI: 10.1016/j.ccm.2021.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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15
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van Rhijn N, Coleman J, Collier L, Moore C, Richardson MD, Bright-Thomas RJ, Jones AM. Meteorological Factors Influence the Presence of Fungi in the Air; A 14-Month Surveillance Study at an Adult Cystic Fibrosis Center. Front Cell Infect Microbiol 2021; 11:759944. [PMID: 34900752 PMCID: PMC8662344 DOI: 10.3389/fcimb.2021.759944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background Cystic fibrosis is an inherited disease that predisposes to progressive lung damage. Cystic fibrosis patients are particularly prone to developing pulmonary infections. Fungal species are commonly isolated in lower airway samples from patients with cystic fibrosis. Fungal spores are prevalent in the air. Methods We performed environmental air sampling surveillance at the Manchester Adult Cystic Fibrosis Centre, UK (MACFC) over a 14-month period to assess fungal growth inside and outside the CF center. Results Airborne counts of fungal spores peaked from May to October, both in outdoor and indoor samples. Collection of meteorological data allowed us to correlate fungal presence in the air with elevated temperatures and low wind speeds. Additionally, we demonstrated patient rooms containing windows had elevated fungal counts compared to rooms not directly connected to the outdoors. Conclusions This study suggests that airborne Aspergillus fumigatus spores were more abundant during the summer months of the survey period, which appeared to be driven by increased temperatures and lower wind speeds. Indoor counts directly correlated to outdoor A. fumigatus levels and were elevated in patient rooms that were directly connected to the outdoor environment via an openable window designed for ventilation purposes. Further studies are required to determine the clinical implications of these findings for cystic fibrosis patients who are predisposed to Aspergillus related diseases, and in particular whether there is seasonal influence on incidence of Aspergillus related conditions and if screening for such complications such be increased during summer months and precautions intensified for those with a known history of Aspergillus related disease.
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Affiliation(s)
- Norman van Rhijn
- Manchester Fungal Infection Group, Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - James Coleman
- Manchester Adult Cystic Fibrosis Centre, Manchester University National Health Service (NHS) Foundation Trust, Manchester, United Kingdom.,Faculty of Biology Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Lisa Collier
- Manchester Adult Cystic Fibrosis Centre, Manchester University National Health Service (NHS) Foundation Trust, Manchester, United Kingdom.,Faculty of Biology Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Caroline Moore
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Mycology Reference Centre, European Confederation of Medical Mycology (ECMM) Excellence Centre of Medical Mycology, Manchester University National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Malcolm D Richardson
- Manchester Fungal Infection Group, Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom.,Mycology Reference Centre, European Confederation of Medical Mycology (ECMM) Excellence Centre of Medical Mycology, Manchester University National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Rowland J Bright-Thomas
- Manchester Adult Cystic Fibrosis Centre, Manchester University National Health Service (NHS) Foundation Trust, Manchester, United Kingdom.,Faculty of Biology Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Andrew M Jones
- Manchester Adult Cystic Fibrosis Centre, Manchester University National Health Service (NHS) Foundation Trust, Manchester, United Kingdom.,Faculty of Biology Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Mycology Reference Centre, European Confederation of Medical Mycology (ECMM) Excellence Centre of Medical Mycology, Manchester University National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
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16
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Jat KR, Walia DK, Khairwa A. Anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2021; 9:CD010288. [PMID: 34550603 PMCID: PMC8457344 DOI: 10.1002/14651858.cd010288.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive multisystem disorder with an approximate prevalence of 1 in 3500 live births. Allergic bronchopulmonary aspergillosis is a lung disease caused by aspergillus-induced hypersensitivity with a prevalence of 2% to 15% in people with cystic fibrosis. The mainstay of treatment includes corticosteroids and itraconazole. The treatment with corticosteroids for prolonged periods of time, or repeatedly for exacerbations of allergic bronchopulmonary aspergillosis, may lead to many adverse effects. The monoclonal anti-IgE antibody, omalizumab, has improved asthma control in severely allergic asthmatics. The drug is given as a subcutaneous injection every two to four weeks. Since allergic bronchopulmonary aspergillosis is also a condition resulting from hypersensitivity to specific allergens, as in asthma, it may be a candidate for therapy using anti-IgE antibodies. Therefore, anti-IgE therapy, using agents like omalizumab, may be a potential therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. This is an updated version of the review. OBJECTIVES To evaluate the efficacy and adverse effects of anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Last search: 09 September 2021. We searched two ongoing trial registries (Clinicaltrials.gov and the WHO trials platform). Date of latest search: 16 August 2021. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing anti-IgE therapy to placebo or other therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias in the included study. They planned to perform data analysis using Review Manager. MAIN RESULTS Only one study enrolling 14 participants was eligible for inclusion in the review. The double-blind study compared a daily dose of 600 mg omalizumab or placebo along with twice daily itraconazole and oral corticosteroids, with a maximum daily dose of 400 mg. Treatment lasted six months but the study was terminated prematurely and complete data were not available. We contacted the study investigator and were told that the study was terminated due to the inability to recruit participants into the study despite all reasonable attempts. One or more serious side effects were encountered in six out of nine (66.67%) and one out of five (20%) participants in omalizumab group and placebo group respectively. AUTHORS' CONCLUSIONS There is lack of evidence for the efficacy and safety of anti-IgE (omalizumab) therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis. There is a need for large prospective randomized controlled studies of anti-IgE therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis with both clinical and laboratory outcome measures such as steroid requirement, allergic bronchopulmonary aspergillosis exacerbations and lung function.
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Affiliation(s)
- Kana R Jat
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Dinesh K Walia
- Department of Community Medicine, Govt. Medical College and Hospital (GMCH), Chandigarh, India
| | - Anju Khairwa
- Department of Pathology, University College of Medical Sciences (UCMS), Delhi, India
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17
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Abstract
In the past three decades, fungal respiratory colonization and fungal respiratory infections increasingly raised concern in cystic fibrosis (CF). Reasons for this are a better knowledge of the pathogenicity of fungi, whereby detection is sought in more and more CF centers, but also improvement of detection methods. However, differences in fungal detection rates within and between geographical regions exist and indicate the need for standardization of mycological examination of respiratory secretions. The still existing lack of standardization also complicates the assessment of fungal pathogenicity, relevance of fungal detection and risk factors for fungal infections. Nevertheless, numerous studies have now been conducted on differences in detection methods, epidemiology, risk factors, pathogenicity and therapy of fungal diseases in CF. Meanwhile, some research groups now have classified fungal disease entities in CF and developed diagnostic criteria as well as therapeutic guidelines.The following review presents an overview on fungal species relevant in CF. Cultural detection methods with their respective success rates as well as susceptibility testing will be presented, and the problem of increasing azole resistance in Aspergillus fumigatus will be highlighted. Next, current data and conflicting evidence on the epidemiology and risk factors for fungal diseases in patients with CF will be discussed. Finally, an overview of fungal disease entities in CF with their current definitions, diagnostic criteria and therapeutic options will be presented.
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18
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Seth D, Poowuttikul P, Pansare M, Abdulhamid I, Kamat D. Allergic Broncho-Pulmonary Aspergillosis. Pediatr Ann 2021; 50:e214-e221. [PMID: 34044705 DOI: 10.3928/19382359-20210421-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Allergic broncho-pulmonary aspergillosis (ABPA) is an immunologically mediated lung disease that usually occurs in people with a diagnosis of asthma or cystic fibrosis. It is a noninvasive lung disease caused by colonization of the airways with Aspergillus fumigatus. In people who are susceptible, Aspergillus leads to an exaggerated immune response and ultimately pulmonary inflammation and lung damage. Patients with ABPA typically present with poorly controlled asthma, recurrent pulmonary infiltrates, and bronchiectasis. Diagnosis of ABPA is established based on a combination of clinical manifestations as well as laboratory and radiological evaluations. Delay in diagnosis can result in airway destruction and pulmonary fibrosis, which may result in significant morbidity and mortality. This article discusses the clinical characteristics, diagnosis, and management of patients with ABPA. It aims to serve as a tool for pediatricians to aid in early recognition of this debilitating disease and consider referral, facilitating early diagnosis and treatment. [Pediatr Ann. 2021;50(5):e214-e221.].
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19
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Agarwal R, Sehgal IS, Dhooria S, Muthu V, Prasad KT, Bal A, Aggarwal AN, Chakrabarti A. Allergic bronchopulmonary aspergillosis. Indian J Med Res 2021; 151:529-549. [PMID: 32719226 PMCID: PMC7602921 DOI: 10.4103/ijmr.ijmr_1187_19] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is an inflammatory disease caused by immunologic reactions initiated against Aspergillus fumigatus colonizing the airways of patients with asthma and cystic fibrosis. The common manifestations include treatment-resistant asthma, transient and fleeting pulmonary opacities and bronchiectasis. It is believed that globally there are about five million cases of ABPA, with India alone accounting for about 1.4 million cases. The occurrence of ABPA among asthmatic patients in special clinics may be as high as 13 per cent. Thus, a high degree of suspicion for ABPA should be entertained while treating a patient with bronchial asthma, particularly in specialized clinics. Early diagnosis and appropriate treatment can delay (or even prevent) the onset of bronchiectasis, which suggests that all patients of bronchial asthma should be screened for ABPA, especially in chest clinics. The current review summarizes the recent advances in the pathogenesis, diagnosis and management of ABPA.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Kuruswamy T Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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20
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Biomarkers for the Diagnosis of Allergic Bronchopulmonary Aspergillosis in Cystic Fibrosis: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1909-1930.e4. [PMID: 33454395 DOI: 10.1016/j.jaip.2020.12.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/03/2020] [Accepted: 12/18/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus fumigatus and impacts 10% of individuals with cystic fibrosis (CF). A diagnosis of ABPA is challenging to establish in CF owing to overlapping clinical and radiologic features with CF lung disease. Recent studies have identified blood tests, imaging, and other biomarkers that may be useful for diagnosis. OBJECTIVE To summarize biomarkers that can aid in the diagnosis of ABPA in CF patients and to quantify their diagnostic accuracy through meta-analysis. METHODS We searched MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials and included studies that used a laboratory technique or imaging modality in CF patients diagnosed with ABPA. Pooled sensitivity and specificity were calculated using a hierarchical summary receiver operating characteristic model. RESULTS We identified 791 articles, of which 29 met our eligibility criteria and 9 were included in the meta-analysis. Hyperattenuating mucus on computed tomography (CT) scan (n = 3 studies; pooled sensitivity 62% and specificity 92%) and serum specific immunoglobulin E against recombinant Aspergillus funigatus antigens f4 (n = 6; 69%, 89%) and f6 (n = 6; 39%, 97%) demonstrated high specificity. Based on single studies, serum thymus and activation regulated chemokine (92%, 94%), stimulated basophil expression of CD203c (94%, 74%), the inverted mucoid impaction signal on magnetic resonance imaging (94%, 100%), and skin prick test with recombinant Aspergillus fumigatus f4 and/or f6 (100%, 100%) showed high sensitivity and specificity. CONCLUSIONS Recent studies have found promising biomarkers for diagnosing ABPA in CF. Further research is needed to improve our understanding of their utility in diagnosis and disease monitoring.
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21
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Grehn C, Eschenhagen P, Temming S, Düesberg U, Neumann K, Schwarz C. Frequent Pet Contact as Risk Factor for Allergic Bronchopulmonary Aspergillosis in Cystic Fibrosis. Front Cell Infect Microbiol 2021; 10:601821. [PMID: 33585274 PMCID: PMC7873990 DOI: 10.3389/fcimb.2020.601821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/24/2020] [Indexed: 01/13/2023] Open
Abstract
Aspergillus fumigatus (Af) frequently colonizes the respiratory tract of patients with cystic fibrosis (CF). Af is associated with loss of pulmonary function and allergic bronchopulmonary aspergillosis (ABPA), a hypersensitivity fungal lung disease. Environmental factors have impact on CF patients’ lung function variation. The aim of this nationwide questionnaire survey was to investigate the amount of CF patients with frequent pet contact including pet species and to examine the potential impact of frequent pet contact on the occurrence of Af colonization and ABPA diagnosis in these patients. The survey was carried out in 31 German CF centers in 2018. A total of 1232 who completed the surveys were included, and statistical analysis was performed by chi-squared test. Within the study cohort 49.8% of subjects (n = 614; CF patients < 18years: 49.4%, n = 234; ≥ 18years: 50.1%, n = 380) reported frequent contact to pets, of which 60.7% reported frequent contact to dogs, 42.3% to cats and other animals. Of those with frequent pet contact, 71.8% (n = 441) had contact to one pet or more pets from the same family. Af colonization was not significantly associated with frequent pet contact. ABPA diagnosis was documented in 16.7% (n = 206) of all included CF patients and was significantly associated with frequent pet contact (18.9%, n = 116, p = 0.042), confirming previous single center examinations. Particularly, patients with frequent contact to dogs showed an increased ABPA prevalence of 21.3%. Frequent pet contact might be a risk factor for ABPA. CF patients who are sensitized to Af should be informed about the increased risk to develop an ABPA by frequent pet contact. Patients with recurrent onset of ABPA should be evaluated in terms of frequent pet contact.
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Affiliation(s)
- Claudia Grehn
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Patience Eschenhagen
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Svenja Temming
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Konrad Neumann
- Institute for Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Schwarz
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
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22
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Lung function over the life course of paediatric and adult patients with cystic fibrosis from a large multi-centre registry. Sci Rep 2020; 10:17421. [PMID: 33060788 PMCID: PMC7567842 DOI: 10.1038/s41598-020-74502-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/29/2020] [Indexed: 12/24/2022] Open
Abstract
A key measure of lung function in people with Cystic Fibrosis (CF) is Forced Expiratory Volume in the first second FEV1 percent predicted (FEV1pp). This study aimed to address challenges in identifying predictors of FEV1pp, specifically dealing with non-linearity and the censoring effect of death. Data was obtained from a large multi-centre Australian Cystic Fibrosis Data Registry (ACFDR). A linear mixed model was used to study FEV1pp as the endpoint. There were 3655 patients (52.4% male) included in our study. Restricted cubic splines were used to fit the non-linear relationship between age of visit and FEV1pp. The following predictors were found to be significant in the multivariate model: age of patient at visit, BMI z-score, age interaction with lung transplantation, insulin dependent diabetes, cirrhosis/portal hypertension, pancreatic insufficiency, Pseudomonas aeruginosa infection and baseline variability in FEV1pp. Those with P. aeruginosa infection had a lower mean difference in FEV1pp of 4.7 units, p < 0.001 compared to those who did not have the infection. Joint modelling with mortality outcome did not materially affect our findings. These models will prove useful for to study the impact of CFTR modulator therapies on rate of change of lung function among patients with CF.
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23
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Wheelock CE, Strandvik B. Abnormal n-6 fatty acid metabolism in cystic fibrosis contributes to pulmonary symptoms. Prostaglandins Leukot Essent Fatty Acids 2020; 160:102156. [PMID: 32750662 DOI: 10.1016/j.plefa.2020.102156] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/24/2020] [Accepted: 06/24/2020] [Indexed: 01/09/2023]
Abstract
Cystic fibrosis (CF) is a recessively inherited fatal disease that is the subject of extensive research and ongoing development of therapeutics targeting the defective protein, cystic fibrosis transmembrane conductance regulator (CFTR). Despite progress, the link between CFTR and clinical symptoms is incomplete. The severe CF phenotypes are associated with a deficiency of linoleic acid, which is the precursor of arachidonic acid. The release of arachidonic acid from membranes via phospholipase A2 is the rate-limiting step for eicosanoid synthesis and is increased in CF, which contributes to the observed inflammation. A potential deficiency of docosahexaenoic acid may lead to decreased levels of specialized pro-resolving mediators. This pathophysiology may contribute to an early and sterile inflammation, mucus production, and to bacterial colonization, which further increases inflammation and potentiates the clinical symptoms. Advances in lipid technology will assist in elucidating the role of lipid metabolism in CF, and stimulate therapeutic modulations of inflammation.
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Affiliation(s)
- Craig E Wheelock
- Division of Physiological Chemistry 2, Dept of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Birgitta Strandvik
- Dept of Biosciences and Nutrition, Karolinska Institutet, Stockholm, Sweden.
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Pavaut G, Kyheng M, Le Rouzic O, Perez T, Wallaert B, Prevotat A. Predictors of massive haemoptysis after a first episode of mild-to-moderate haemoptysis in patients with cystic fibrosis. ERJ Open Res 2020; 6:00382-2020. [PMID: 32963988 PMCID: PMC7487340 DOI: 10.1183/23120541.00382-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/19/2020] [Indexed: 11/21/2022] Open
Abstract
The main cause of death of cystic fibrosis (CF) patients is respiratory disease due to secondary infections, haemoptysis, pneumothorax, and respiratory failure [1]. In a study of 129 French CF patients who died between 2007 and 2010 without receiving lung transplantation, 8.5% of deaths were due to haemoptysis [2]. Factors associated with an increased risk of haemoptysis in CF patients include older age, advanced lung disease (forced expiratory volume in 1 s (FEV1) <70% predicted), airway colonisation by Pseudomonas aeruginosa [3], CF-related diabetes, portal hypertension, and liver cirrhosis [4]. To our knowledge, there have been no studies of the risk factors for the development of massive haemoptysis (MH) in CF patients who have previously experienced an episode of mild-to-moderate haemoptysis. Mild-to-moderate haemoptysis (m-mH) is common in patients with cystic fibrosis but the risk of subsequent massive haemoptysis (MH) is not known. Allergic bronchopulmonary aspergillosis and diabetes were significant predictors of MH subsequent to m-mH.https://bit.ly/30093Hw
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Kids, Difficult Asthma and Fungus. J Fungi (Basel) 2020; 6:jof6020055. [PMID: 32349347 PMCID: PMC7345103 DOI: 10.3390/jof6020055] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 04/24/2020] [Accepted: 04/26/2020] [Indexed: 12/28/2022] Open
Abstract
Fungi have many potential roles in paediatric asthma, predominantly by being a source of allergens (severe asthma with fungal sensitization, SAFS), and also directly damaging the epithelial barrier and underlying tissue by releasing proteolytic enzymes (fungal bronchitis). The umbrella term ‘fungal asthma’ is proposed for these manifestations. Allergic bronchopulmonary aspergillosis (ABPA) is not a feature of childhood asthma, for unclear reasons. Diagnostic criteria for SAFS are based on sensitivity to fungal allergen(s) demonstrated either by skin prick test or specific IgE. In children, there are no exclusion criteria on total IgE levels or IgG precipitins because of the rarity of ABPA. Diagnostic criteria for fungal bronchitis are much less well established. Data in adults and children suggest SAFS is associated with worse asthma control and greater susceptibility to asthma attacks than non-sensitized patients. The data on whether anti-fungal therapy is beneficial are conflicting. The pathophysiology of SAFS is unclear, but the epithelial alarmin interleukin-33 is implicated. However, whether individual fungi have different pathobiologies is unclear. There are many unanswered questions needing further research, including how fungi interact with other allergens, bacteria, and viruses, and what optimal therapy should be, including whether anti-neutrophilic strategies, such as macrolides, should be used. Considerable further research is needed to unravel the complex roles of different fungi in severe asthma.
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Pollak M, Shaw M, Wilson D, Grasemann H, Ratjen F. Bronchodilator responsiveness in children with cystic fibrosis and allergic bronchopulmonary aspergillosis. Eur Respir J 2020; 56:13993003.00175-2020. [DOI: 10.1183/13993003.00175-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/31/2020] [Indexed: 12/26/2022]
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Martín-Gómez MT. Taking a look on fungi in cystic fibrosis: More questions than answers. Rev Iberoam Micol 2020; 37:17-23. [PMID: 31928888 DOI: 10.1016/j.riam.2019.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/21/2019] [Accepted: 10/30/2019] [Indexed: 02/07/2023] Open
Abstract
Cystic fibrosis (CF) is one of the most frequent recessive inherited diseases in western countries. Advances in medical care have led to a substantial increase in the life expectancy of CF patients. Survival beyond adolescence has permitted to see fungi not only as late colonizers, but also as potential pathogens responsible of allergic reactions and chronic infections related to lung function deterioration. The role of fungi, nevertheless, has been overlooked until recently. As a result, a number of questions on their epidemiology, clinical significance, or diagnosis, among others, remain unanswered. Besides more in depth studies about the extent of the deleterious effect of fungi on the CF host, new technologies may provide the key to understand its pathogenic role, its interaction with other microbial components of the respiratory microbiota, and should pave the way to define subsets of patients at risk who would benefit from specific therapy. This review is intended to provide a quick overview on what we know about the presence of fungi in the CF airway and its repercussion in the host, and to point out some of the many knowledge gaps needed to understand and advance in the management of fungi in the airway of CF subjects.
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Fungal Infections and ABPA. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sunman B, Ademhan Tural D, Ozsezen B, Emiralioglu N, Yalcin E, Özçelik U. Current Approach in the Diagnosis and Management of Allergic Bronchopulmonary Aspergillosis in Children With Cystic Fibrosis. Front Pediatr 2020; 8:582964. [PMID: 33194914 PMCID: PMC7606581 DOI: 10.3389/fped.2020.582964] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder characterized by a hypersensitivity reaction to Aspergillus fumigatus, and almost always seen in patients with cystic fibrosis (CF) and asthma. Fungal hyphae leads to an ongoing inflammation in the airways that may result in bronchiectasis, fibrosis, and eventually loss of lung function. Despite the fact that ABPA is thought to be more prevalent in CF than in asthma, the literature on ABPA in CF is more limited. The diagnosis is challenging and may be delayed because it is made based on a combination of clinical features, and radiologic and immunologic findings. With clinical deterioration of a patient with CF, ABPA is important to be kept in mind because clinical manifestations mimic pulmonary exacerbations of CF. Early diagnosis and appropriate treatment are important in preventing complications related to ABPA. Treatment modalities involve the use of anti-inflammatory agents to suppress the immune hyperreactivity and the use of antifungal agents to reduce fungal burden. Recently, in an effort to treat refractory patients or to reduce adverse effects of steroids, other treatment options such as monoclonal antibodies have started to be used. Intensive research of these new agents in the treatment of children is being conducted to address insufficient data.
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Affiliation(s)
- Birce Sunman
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dilber Ademhan Tural
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Beste Ozsezen
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nagehan Emiralioglu
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ebru Yalcin
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Uğur Özçelik
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Muthu V, Agarwal R. Allergic Bronchopulmonary Aspergillosis. CLINICAL PRACTICE OF MEDICAL MYCOLOGY IN ASIA 2020:137-164. [DOI: 10.1007/978-981-13-9459-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Harun SN, Holford NHG, Grimwood K, Wainwright CE, Hennig S. Pseudomonas aeruginosa eradication therapy and risk of acquiring Aspergillus in young children with cystic fibrosis. Thorax 2019; 74:740-748. [DOI: 10.1136/thoraxjnl-2018-211548] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/31/2019] [Accepted: 05/08/2019] [Indexed: 12/20/2022]
Abstract
BackgroundWhile Aspergillus detection rates in adults, adolescents and older children with cystic fibrosis (CF) have increased, the risk of acquiring this fungal pathogen in young children is unknown.AimTo determine the risk and explanatory factors of acquiring Aspergillus in children with CF by age 5 years.MethodsCross-sectional analysis of clinical, bronchoalveolar lavage and treatment data from the Australasian Cystic Fibrosis Bronchoalveolar Lavage study was used to identify predictive factors for detecting Aspergillus at age 5 years. A parametric repeated time-to-event model quantitatively described the risk and factors associated with acquiring Aspergillus and Pseudomonas aeruginosa from birth until age 5 years.ResultsCross-sectional analysis found that the number of P. aeruginosa eradication courses increased the odds of detecting Aspergillus at age 5 years (OR 1.61, 95% CI 1.23 to 2.12). The median (IQR) age for the first P. aeruginosa positive culture was 2.38 (1.32–3.79) years and 3.69 (1.68–4.74) years for the first Aspergillus positive culture. The risk of P. aeruginosa and Aspergillus events changes with time after the first year of study entry. It also decreases for P. aeruginosa after completing P. aeruginosa eradication (HR 0.15, 95% CI 0.00 to 0.79), but increases for Aspergillus events (HR 2.75, 95% CI 1.45 to 5.41). The risk of acquiring both types of events increases after having had a previous event.ConclusionIn young children with CF, completing P. aeruginosa eradication therapy and previous Aspergillus events are associated with increased risk of acquiring Aspergillus.
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Warris A, Bercusson A, Armstrong-James D. Aspergillus colonization and antifungal immunity in cystic fibrosis patients. Med Mycol 2019; 57:S118-S126. [PMID: 30816976 DOI: 10.1093/mmy/myy074] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/20/2018] [Accepted: 07/26/2018] [Indexed: 12/11/2022] Open
Abstract
Cystic fibrosis (CF), caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, is the most common inherited life-limiting disease in North European people affecting 90,000 people worldwide. Progressive lung damage caused by recurrent infection and chronic airway inflammation is the major determinant of survival with a median age at death of 29 years. Approximately 60% of CF patients are infected with Aspergillus fumigatus, a ubiquitous environmental fungus, and its presence has been associated with accelerated lung function decline. Half of the patients infected with Aspergillus are <18 years of age. Yet time of acquisition of this fungus and determinants of CF-related Aspergillus disease severity and progression are not known. CFTR expression has been demonstrated in cells of the innate and adaptive immune system and has shown to be critical for normal function. Research delineating the role of CFTR-deficient phagocytes in Aspergillus persistence and infection in the CF lung, has only recently received attention. In this concise review we aim to present the current understanding with respect to when people with CF acquire infection with A. fumigatus and antifungal immune responses by CF immune cells.
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Affiliation(s)
- Adilia Warris
- MRC Centre for Medical Mycology, Aberdeen Fungal Group, University of Aberdeen, United Kingdom
| | - Amelia Bercusson
- National Heart and Lung Institute, Imperial College London, United Kingdom
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Ashkenazi M, Sity S, Sarouk I, Bar Aluma BE, Dagan A, Bezalel Y, Bentur L, De Boeck K, Efrati O. Omalizumab in allergic bronchopulmonary aspergillosis in patients with cystic fibrosis. J Asthma Allergy 2018; 11:101-107. [PMID: 29950869 PMCID: PMC6016275 DOI: 10.2147/jaa.s156049] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Allergic bronchopulmonary aspergillosis (ABPA) is a condition characterized by a Th2 response, serum eosinophilia, and increased total serum IgE to Aspergillus fumigatus. ABPA occurs in cystic fibrosis (CF) and asthma. Omalizumab is a humanized recombinant monoclonal antibody against IgE. Previous studies reported borderline results when treating ABPA with omalizumab. Methods A retrospective study to investigate the efficacy of omalizumab in the treatment of ABPA in CF patients was conducted at 3 CF centers in Israel and Belgium. Data were obtained from the digital archive. We measured 4 outcome parameters: forced expiratory volume in 1 second, body mass index, pulmonary exacerbations, and steroid sparing. Results The database was composed on the records of 9 patients. None of the outcome parameters showed any improvement. A favorable outcome was observed in patients with higher levels of posttreatment total IgE than those with lower levels. CF-related diabetes and male gender showed trends for poorer outcomes. Conclusion No benefits were detected on treating ABPA in CF with omlaizumb. Monitoring the total IgE was not helpful. A prospective randomized double-blind study is needed.
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Affiliation(s)
- Moshe Ashkenazi
- Pediatric Pulmonology and National CF Center, Edmond and Lilly Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Saray Sity
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ifat Sarouk
- Pediatric Pulmonology and National CF Center, Edmond and Lilly Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bat El Bar Aluma
- Pediatric Pulmonology and National CF Center, Edmond and Lilly Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Dagan
- Pediatric Pulmonology and National CF Center, Edmond and Lilly Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Bezalel
- Pediatric Pulmonology and National CF Center, Edmond and Lilly Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lea Bentur
- Pediatric Pulmonology Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Kris De Boeck
- Pediatric Pulmonology, Department of Pediatrics, University of Leuven, Leuven, Belgium
| | - Ori Efrati
- Pediatric Pulmonology and National CF Center, Edmond and Lilly Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Jat KR, Walia DK, Khairwa A. Anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2018; 3:CD010288. [PMID: 29551015 PMCID: PMC6494205 DOI: 10.1002/14651858.cd010288.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive multisystem disorder with an approximate prevalence of 1 in 3500 live births. Allergic bronchopulmonary aspergillosis is a lung disease caused by aspergillus-induced hypersensitivity with a prevalence of 2% to 15% in people with cystic fibrosis. The mainstay of treatment includes corticosteroids and itraconazole. The treatment with corticosteroids for prolonged periods of time, or repeatedly for exacerbations of allergic bronchopulmonary aspergillosis, may lead to many adverse effects. The monoclonal anti-IgE antibody, omalizumab, has improved asthma control in severely allergic asthmatics. The drug is given as a subcutaneous injection every two to four weeks. Since allergic bronchopulmonary aspergillosis is also a condition resulting from hypersensitivity to specific allergens, as in asthma, it may be a candidate for therapy using anti-IgE antibodies. Therefore, anti-IgE therapy, using agents like omalizumab, may be a potential therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. This is an updated version of the review. OBJECTIVES To evaluate the efficacy and adverse effects of anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Last search: 29 September 2017.We searched two ongoing trial registries (Clinicaltrials.gov and the WHO trials platform). Date of latest search: 24 January 2018. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing anti-IgE therapy to placebo or other therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias in the included study. They planned to perform data analysis using Review Manager. MAIN RESULTS Only one study enrolling 14 participants was eligible for inclusion in the review. The double-blind study compared a daily dose of 600 mg omalizumab or placebo along with twice daily itraconazole and oral corticosteroids, with a maximum daily dose of 400 mg. Treatment lasted six months but the study was terminated prematurely and complete data were not available. We contacted the study investigator and were told that the study was terminated due to the inability to recruit participants into the study despite all reasonable attempts. One or more serious side effects were encountered in six out of nine (66.67%) and one out of five (20%) participants in omalizumab group and placebo group respectively. AUTHORS' CONCLUSIONS There is lack of evidence for the efficacy and safety of anti-IgE (omalizumab) therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis. There is a need for large prospective randomized controlled studies of anti-IgE therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis with both clinical and laboratory outcome measures such as steroid requirement, allergic bronchopulmonary aspergillosis exacerbations and lung function.
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Affiliation(s)
- Kana R Jat
- All India Institute of Medical Sciences (AIIMS)Department of PediatricsAnsari NagarNew DelhiDelhiIndia110029
| | - Dinesh K Walia
- Govt. Medical College and Hospital (GMCH)Department of Community MedicineSector‐32ChandigarhChandigarh UTIndia160030
| | - Anju Khairwa
- Postgraduate Institute of Medical Education and Research (PGIMER)Department of PathologySector‐12ChandigarhChandigarh UTIndia160012
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Suzuki S, Asakura T, Namkoong H, Okamori S, Yagi K, Kamata H, Uwamino Y, Funatsu Y, Nakano Y, Nishimura T, Ishii M, Ebihara T, Betsuyaku T, Hasegawa N. Aspergillus precipitating antibody in patients with Mycobacterium avium complex lung disease: A cross-sectional study. Respir Med 2018; 138:1-6. [PMID: 29724379 DOI: 10.1016/j.rmed.2018.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/25/2018] [Accepted: 03/11/2018] [Indexed: 01/04/2023]
Abstract
RATIONALE Little is known about the role of Aspergillus precipitating antibody (APAb) in patients with Mycobacterium avium complex lung disease (MAC-LD). OBJECTIVES We investigated the clinical characteristics of patients with MAC-LD positive for APAb. METHODS We conducted a cross-sectional study targeting patients with MAC-LD. APAb was checked in all participants. Clinical variables included laboratory data, pulmonary function, high-resolution computed tomography findings, and health-related quality of life. RESULTS We analyzed 109 consecutive patients. Their median age was 68 years, and the median duration of MAC-LD was 4.8 years. Twenty (18.3%) patients tested positive for APAb. APAb-positive patients had significantly longer duration of MAC-LD (9.4 vs. 4.0 years, P = 0.017), more severe bronchiectasis evaluated by modified Reiff score (6.5 vs. 4, P = 0.0049), and lower forced expiratory volume in 1 s (%FEV1) (75.1% vs. 86.2%, P = 0.013) than APAb-negative patients. Analysis of covariance adjusted for background factors and underlying pulmonary disease revealed that %FEV1 was also significantly lower in patients with APAb (P = 0.045). Ten patients were newly diagnosed with chronic pulmonary aspergillosis (N = 5) or allergic bronchopulmonary aspergillosis (N = 5). CONCLUSIONS APAb is associated with lower pulmonary function, and observed especially in patients with longer duration of MAC-LD and severe bronchiectasis, even in the absence of cavitary lesions.
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Affiliation(s)
- Shoji Suzuki
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Asakura
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ho Namkoong
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuma Yagi
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kamata
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshifumi Uwamino
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Funatsu
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Nakano
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | | | - Makoto Ishii
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tamotsu Ebihara
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Tomoko Betsuyaku
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hasegawa
- Center for Infectious Diseases and Infection Control, Keio University School of Medicine, Tokyo, Japan.
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Alyasin S, Moghtaderi M, Farjadian S, Babaei M, Teshnizi SH. Allergic bronchopulmonary aspergillosis in patients with cystic fibrosis and non-cystic fibrosis bronchiectasis. Electron Physician 2018; 10:6273-6278. [PMID: 29588830 PMCID: PMC5854004 DOI: 10.19082/6273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 08/26/2017] [Indexed: 11/20/2022] Open
Abstract
Background Aspergillus sensitization (AS) and allergic bronchopulmonary aspergillosis (ABPA) can occur as a cause of permanent lung damage in patients with cystic fibrosis (CF) and non-CF bronchiectasis. Objective The aim of this study was to determine the frequency of AS and ABPA in patients with CF and non-CF bronchiectasis in southwestern Iran. Methods This cross-sectional study was conducted on 33 patients with CF and 27 patients with non-CF bronchiectasis from southwestern Iran who were referred to Namazi Hospital affiliated to Shiraz University of Medical Sciences from July 2015 to February 2016. Skin prick test to Aspergillus fumigatus, peripheral blood eosinophil count, total serum IgE, specific IgE and IgG against Aspergillus fumigatus as well as radiologic chest studies were done for each patient. Statistical analysis was done by Mann-Whitney U test, Fisher Exact test, and Kappa weighted in SPSS software version 18. Level of significance was set at p<0.05. Results Nine patients with CF (27.3%) and one patient with non-CF bronchiectasis (3.7%) had positive skin tests to Aspergillus. There was 81.2% agreement between positive skin test and specific IgE to Aspergillus fumigatus (p<0.001). Three patients with CF (9%) met the diagnostic criteria for ABPA, whereas ABPA was not seen in patients with non-CF bronchiectasis. Conclusion ABPA was low in this study, considering more frequency of AS in patients with cystic fibrosis, clinicians should keep in mind the diagnosis of ABPA for those CF patients that do not respond to usual medical therapy and have positive skin tests to Aspergillus allergens.
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Affiliation(s)
- Soheila Alyasin
- MD, Allergy Research Center, Department of Pediatrics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mozhgan Moghtaderi
- MD, Allergy Research Center, Allergy Clinic of Ali-asghar Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shirin Farjadian
- Ph.D., Professor in Immunology, Allergy Research Center, Department of Immunology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Babaei
- M.Sc. in Microbiology, Allergy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saeed Hosseini Teshnizi
- Ph.D. Candidate in Biostatistics, Clinical Research Development Center of Children Hospital, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
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Scheffold A, Schwarz C, Bacher P. Fungus-Specific CD4 T Cells as Specific Sensors for Identification of Pulmonary Fungal Infections. Mycopathologia 2017; 183:213-226. [PMID: 29168073 DOI: 10.1007/s11046-017-0229-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 11/14/2017] [Indexed: 12/24/2022]
Abstract
Patients with cystic fibrosis (CF) suffer from chronic lung infections, caused by bacterial, viral or fungal pathogens, which determine morbidity and mortality. The contribution of individual pathogens to chronic disease and acute lung exacerbations is often difficult to determine due to the complex composition of the lung microbiome in CF. In particular, the relevance of fungal pathogens in CF airways remains poorly understood due to limitations of current diagnostics to identify the presence of fungal pathogens and to resolve the individual host-pathogen interaction status. T-lymphocytes play an essential role in host defense against pathogens, but also in inappropriate immune reactions such as allergies. They have the capacity to specifically recognize and discriminate the different pathogens and orchestrate a diverse array of effector functions. Thus, the analysis of the fungus-specific T cell status of an individual can in principle provide detailed information about the identity of the fungal pathogen(s) encountered and the actual fungus-host interaction status. This may allow to classify patients, according to appropriate (protective) or inappropriate (pathology-associated) immune reactions against individual fungal pathogens. However, T cell-based diagnostics are currently not part of the clinical routine. The identification and characterization of fungus-specific T cells in health and disease for diagnostic purposes are associated with significant challenges. Recent technological developments in the field of fungus-specific T helper cell detection provide new insights in the host T cell-fungus interaction. In this review, we will discuss basic principles and the potential of T cell-based diagnostics, as well as the perspectives and further needs for use of T cells for improved clinical diagnostics of fungal diseases.
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Affiliation(s)
- Alexander Scheffold
- Department of Cellular Immunology, Clinic for Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- German Rheumatism Research Centre (DRFZ) Berlin, Leibniz Association, Berlin, Germany.
| | - Carsten Schwarz
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Centre Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Petra Bacher
- Department of Cellular Immunology, Clinic for Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Organization of Patient Management and Fungal Epidemiology in Cystic Fibrosis. Mycopathologia 2017; 183:7-19. [PMID: 29098487 PMCID: PMC7089279 DOI: 10.1007/s11046-017-0205-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/26/2017] [Indexed: 12/26/2022]
Abstract
The achievement of a better life for cystic fibrosis (CF) patients is mainly caused by a better management and infection control over the last three decades. Herein, we want to summarize the cornerstones for an effective management of CF patients and to give an overview of the knowledge about the fungal epidemiology in this clinical context in Europe. Data from a retrospective analysis encompassing 66,616 samples from 3235 CF patients followed-up in 9 CF centers from different European countries are shown.
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Increasing Total Serum IgE, Allergic Bronchopulmonary Aspergillosis, and Lung Function in Cystic Fibrosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1591-1598.e6. [DOI: 10.1016/j.jaip.2017.03.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 02/23/2017] [Accepted: 03/28/2017] [Indexed: 11/19/2022]
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40
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Invasive Pulmonary Fungal Infections in Cystic Fibrosis. Mycopathologia 2017; 183:33-43. [DOI: 10.1007/s11046-017-0199-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/20/2017] [Indexed: 11/25/2022]
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41
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Kaditis AG, Miligkos M, Bossi A, Colombo C, Hatziagorou E, Kashirskaya N, de Monestrol I, Thomas M, Mei-Zahav M, Chrousos G, Zolin A. Effect of allergic bronchopulmonary aspergillosis on FEV 1 in children and adolescents with cystic fibrosis: a European Cystic Fibrosis Society Patient Registry analysis. Arch Dis Child 2017; 102:742-747. [PMID: 28325727 DOI: 10.1136/archdischild-2016-311132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 02/27/2017] [Accepted: 03/02/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the effect of allergic bronchopulmonary aspergillosis (ABPA) on FEV1 percent predicted in children and adolescents with cystic fibrosis. DESIGN Longitudinal data analysis (2008-2010). SETTING Patients participating in the European Cystic Fibrosis Society Patient Registry. PARTICIPANTS 3350 patients aged 6-17 years. MAIN OUTCOME MEASURE FEV1 percent predicted was the main outcome measure (one measurement per year per child). To describe the effect of ABPA (main explanatory variable) on FEV1 while controlling for other prognostic factors, a linear mixed effects regression model was applied. RESULTS In 2008, the mean (±SD) FEV1 percent predicted was 78.6 (±20.6) in patients with ABPA (n=346) and 88 (±19.8) in those without ABPA (n=2806). After considering other variables, FEV1 in subjects with ABPA on entry to the study was 1.47 percentage points lower than FEV1 in patients of similar age without ABPA (p=0.003). There was no FEV1 decline associated with ABPA over the subsequent study years as the interaction of ABPA with age was not significant (p>0.05). For patients aged 11.82 years (population mean age), poor body mass index had the greatest impact on FEV1 in 2008, followed by high-risk genotype (two severe mutations), female gender, diabetes mellitus, chronic Pseudomonas aeruginosa infection and ABPA in descending order of effect size. CONCLUSIONS In contrast to the common clinical belief of ABPA having a serious impact on lung function, the difference in FEV1 between young patients with and without the complication was found to be modest when the effect of other prognostic factors was considered.
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Affiliation(s)
- Athanasios G Kaditis
- Paediatric Pulmonology Unit, First Department of Paediatrics, National and Kapodistrian University of Athens and Aghia Sophia Children's Hospital, Athens, Greece
| | - Michael Miligkos
- Paediatric Pulmonology Unit, First Department of Paediatrics, National and Kapodistrian University of Athens and Aghia Sophia Children's Hospital, Athens, Greece.,Laboratory of Biomathematics, University of Thessaly School of Medicine, Athens, Greece
| | - Anna Bossi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Carla Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Elpis Hatziagorou
- Paediatric Pulmonology Unit and Cystic Fibrosis Unit, 3rd Paediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nataliya Kashirskaya
- Department of Genetic Epidemiology, Federal State Budgetary Institution 'Research Centre for Medical Genetics', Moscow, Russian Federation
| | - Isabelle de Monestrol
- Stockholm Cystic Fibrosis Centre Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Muriel Thomas
- Belgian Cystic Fibrosis Registry, Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium
| | - Meir Mei-Zahav
- Respiratory Institute, Schneider Children's Medical Centre of Israel, Sackler School of Medicine, Tel Aviv University, Israel
| | - George Chrousos
- First Department of Paediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Zolin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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42
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Aguiar SS, Damaceno N, Forte WCN. EXAMES PARA AVALIAR A SENSIBILIZAÇÃO AO ASPERGILLUS FUMIGATUS EM FIBROSE CÍSTICA. REVISTA PAULISTA DE PEDIATRIA 2017; 35:252-257. [PMID: 28977288 PMCID: PMC5606171 DOI: 10.1590/1984-0462/;2017;35;3;00003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/30/2016] [Indexed: 11/23/2022]
Abstract
Objective: To evaluate the results of the tests used to identify the IgE mediated sensitization to Aspergillus fumigatus in patients with cystic fibrosis. Methods: This is a cross-sectional descriptive study with a convenience sample of 86 patients diagnosed with cystic fibrosis in the Reference Service in Cystic Fibrosis at a tertiary teaching hospital. The following tests were performed to assess the sensitization to A. fumigatus in patients with cystic fibrosis: Total serum IgE, eosinophil count, fungus detection through oropharyngeal swab or sputum culture, serum-specific IgE, and immediate-type hypersensitivity (IgE) skin tests. We compared the results of the different tests performed. Results: In 33 (38.4%) patients with cystic fibrosis, with ages ranging from 1 to 33 years (median of 8 years), the IgE-mediated A. fumigatus sensitization test results were: in 16 patients, there was an increase in serum-specific IgE (>0.35 kU/L); in 23, skin tests were positive; and six had sensitization in both tests. We observed two patients with eosinophilia (>1,000 eosinophils/mm3) and seven with increasing total serum IgE (>1,000 IU/mL), all of whom obtained negative results in skin tests and had no IgE increase specific to A. fumigatus. A. fumigatus was not detected in oropharyngeal swabs and/or sputum culture of any patients. Conclusions: We conclude that, among the tests used to assess sensitization to A. fumigatus in cystic fibrosis patients, both serum-specific IgE and immediate-type hypersensitivity (IgE) skin tests are required. Serum eosinophilia and respiratory secretion culture were not essential in this study.
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Affiliation(s)
| | - Neiva Damaceno
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brasil
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43
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Gupta K, Gupta P, Mathew JL, Bansal A, Singh G, Singh M, Chakrabarti A. Fatal Disseminated Aspergillus penicillioides Infection in a 3-Month-Old Infant with Suspected Cystic Fibrosis: Autopsy Case Report with Review of Literature. Pediatr Dev Pathol 2017; 19:506-511. [PMID: 26579953 DOI: 10.2350/15-10-1729-cr.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with cystic fibrosis (CF) often are colonized by Aspergillus species in their respiratory tract, but invasive aspergillosis is a rare complication. We describe the autopsy findings of an infant with cystic fibrosis who had fatal disseminated aspergillosis. The causative agent was identified as A. penicillioides by molecular technique. To our knowledge, this is the first report of disseminated aspergillosis caused by A. penicillioides in any type of patient. The literature on invasive aspergillosis in patients with cystic fibrosis also is reviewed.
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Affiliation(s)
- Kirti Gupta
- 1 Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Parikshaa Gupta
- 1 Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Joseph L Mathew
- 2 Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Bansal
- 2 Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Gangandeep Singh
- 3 Department of Medical Mycology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Meenu Singh
- 2 Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- 3 Department of Medical Mycology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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44
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Somayaji R, Ramos KJ, Kapnadak SG, Aitken ML, Goss CH. Common clinical features of CF (respiratory disease and exocrine pancreatic insufficiency). Presse Med 2017; 46:e109-e124. [PMID: 28554722 DOI: 10.1016/j.lpm.2017.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/06/2017] [Accepted: 03/29/2017] [Indexed: 12/17/2022] Open
Abstract
First described as a disease of the pancreas, cystic fibrosis is a genetically inherited progressive disease affecting multiple organ systems. Pulmonary and pancreatic involvement is common in individuals with cystic fibrosis, and the former is attributable to most of the mortality that occurs with the condition. This chapter provides an overview of a clinical approach to the pulmonary and pancreatic manifestations of cystic fibrosis.
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Affiliation(s)
- Ranjani Somayaji
- University of Calgary, Department of Medicine, Calgary, AB, Canada
| | - Kathleen J Ramos
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Siddhartha G Kapnadak
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Moira L Aitken
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Christopher H Goss
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA; University of Washington, Department of Pediatrics, Division of Pediatric Pulmonology, Seattle, WA, USA; Seattle Children's Research Institute, Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle, WA, USA.
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45
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Nové-Josserand R, Grard S, Auzou L, Reix P, Murris-Espin M, Brémont F, Mammar B, Mely L, Hubert D, Durieu I, Burgel PR. Case series of omalizumab for allergic bronchopulmonary aspergillosis in cystic fibrosis patients. Pediatr Pulmonol 2017; 52:190-197. [PMID: 27717223 DOI: 10.1002/ppul.23612] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/05/2016] [Accepted: 09/19/2016] [Indexed: 11/08/2022]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) affects up to 15% of patients with cystic fibrosis (CF). Corticosteroids are used as first-line therapy, but relapse and adverse effects commonly occur. Case reports have suggested the efficacy of the anti-IgE recombinant humanized monoclonal antibody omalizumab. A retrospective multicenter observational French study retrieved 32 CF patients (11 children and 21 adults) who have received omalizumab for more than 3 months in the context of ABPA. Clinical characteristics, concomitant medications (inhaled and oral corticosteroids, antifungal drugs), lung function, body mass index (BMI), and serum IgE were compared at the start and during the first year of omalizumab therapy. Omalizumab-related adverse effects and costs were also evaluated. No significant difference with omalizumab could be demonstrated with regard to lung function, BMI, or the number of patients receiving oral corticosteroids. At the time of initiation of omalizumab, 56% of patients were receiving oral corticosteroids. Five patients were able to discontinue corticosteroids during follow-up and nine patients were able to reduce their daily dose. A total of 78% of the patients had received antifungal therapy at the time of the initiation of omalizumab. Treatment tolerance was good (12.5% of patients experienced side effects). The median cost of omalizumab treatment was €3,620 per patient per month. Omalizumab may represent a steroid-sparing therapy in CF patients with ABPA. A randomized-controlled trial is urgently required to provide higher level of evidence regarding the efficacy and cost-effectiveness of omalizumab in CF patients with ABPA. Pediatr Pulmonol. 2017;52:190-197. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Soazic Grard
- CF Adult Center, University Center Hospital Lyon-Sud, Lyon, France
| | - Lila Auzou
- Department of Respiratory Disease and Adult CF Center, Cochin Hospital, AP-HP, Paris, France
| | | | - Marlène Murris-Espin
- Pulmonology Unit, Adult CF Center, Rangueil-Larrey University Hospital, Toulouse, France
| | - François Brémont
- University Center Hospital-CF Pediatric Center, Toulouse, France
| | | | | | - Dominique Hubert
- Department of Respiratory Disease and Adult CF Center, Cochin Hospital, AP-HP, Paris, France
| | - Isabelle Durieu
- CF Adult Center, University Center Hospital Lyon-Sud, Lyon, France
| | - Pierre-Régis Burgel
- Department of Respiratory Disease and Adult CF Center, Cochin Hospital, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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46
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Janahi IA, Rehman A, Al-Naimi AR. Allergic bronchopulmonary aspergillosis in patients with cystic fibrosis. Ann Thorac Med 2017; 12:74-82. [PMID: 28469716 PMCID: PMC5399694 DOI: 10.4103/atm.atm_231_16] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder that often occurs in patients with asthma or cystic fibrosis (CF) and is characterized by a hypersensitivity response to the allergens of the fungus Aspergillus fumigatus. In patients with CF, growth of A. fumigatus hyphae within the bronchial lumen triggers an immunoglobulin E (IgE)-mediated hypersensitivity response that results in airway inflammation, bronchospasm, and bronchiectasis. In most published studies, the prevalence of ABPA is about 8.9% in patients with CF. Since the clinical features of this condition overlap significantly with that of CF, ABPA is challenging to diagnose and remains underdiagnosed in many patients. Diagnosis of ABPA in CF patients should be sought in those with evidence of clinical and radiologic deterioration that is not attributable to another etiology, a markedly elevated total serum IgE level (while off steroid therapy) and evidence of A. fumigatus sensitization. Management of ABPA involves the use of systemic steroids to reduce inflammation and modulate the immune response. In patients who do not respond to steroids or cannot tolerate them, antifungal agents should be used to reduce the burden of A. fumigatus allergens. Recent studies suggest that omalizumab may be an effective option to reduce the frequency of ABPA exacerbations in patients with CF. Further randomized controlled trials are needed to better establish the efficacy of omalizumab in managing patients with CF and ABPA.
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Affiliation(s)
- Ibrahim Ahmed Janahi
- Department of Clinical Pediatrics, Weill Cornell Medical College-Qtar, Doha, Qatar.,Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Rehman
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Amal Rashid Al-Naimi
- Department of Clinical Pediatrics, Weill Cornell Medical College-Qtar, Doha, Qatar.,Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
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47
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Agarwal R, Sehgal IS, Dhooria S, Aggarwal AN. Developments in the diagnosis and treatment of allergic bronchopulmonary aspergillosis. Expert Rev Respir Med 2016; 10:1317-1334. [PMID: 27744712 DOI: 10.1080/17476348.2016.1249853] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder characterized by recurrent episodes of wheezing, fleeting pulmonary opacities and bronchiectasis. It is the most prevalent of the Aspergillus disorders with an estimated five million cases worldwide. Despite six decades of research, the pathogenesis, diagnosis and treatment of this condition remains controversial. The International Society for Human and Animal Mycology has formed a working group to resolve the controversies around this entity. In the year 2013, this group had proposed new criteria for diagnosis and staging, and suggested a treatment protocol for the management of this disorder. Since then, several pieces of new evidence have been published in the investigation and therapeutics of this condition. Areas covered: A non-systematic review of the available literature was performed. We summarize the current evidence in the evaluation and treatment of this enigmatic disorder. We suggest modifications to the existing criteria and propose a new scoring system for the diagnosis of ABPA. Expert commentary: All patients with asthma and cystic fibrosis should routinely be screened for ABPA using A. fumigatus-specific IgE levels. Glucocorticoids should be used as the first-line of therapy in ABPA, and itraconazole reserved in those with recurrent exacerbations and glucocorticoid-dependent disease.
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Affiliation(s)
- Ritesh Agarwal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Inderpaul S Sehgal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Sahajal Dhooria
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Ashutosh N Aggarwal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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48
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Maturu VN, Agarwal R. Prevalence of Aspergillus sensitization and allergic bronchopulmonary aspergillosis in cystic fibrosis: systematic review and meta-analysis. Clin Exp Allergy 2016; 45:1765-78. [PMID: 26177981 DOI: 10.1111/cea.12595] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/08/2015] [Accepted: 07/03/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prevalence of Aspergillus sensitization (AS) and allergic bronchopulmonary aspergillosis (ABPA) in cystic fibrosis (CF) has been varyingly reported. The aim of this systematic review was to estimate the overall prevalence of AS/ABPA in CF. METHODS We searched the PubMed and EmBase databases for studies reporting the prevalence of AS/ABPA in CF. We calculated the proportion with 95% confidence interval (CI) to assess the prevalence of AS and ABPA in the individual studies and then pooled the results using a random effects model. Statistical heterogeneity was assessed using the I2 test while publication bias was assessed using both graphical and statistical methods. RESULTS Our search yielded 64 eligible studies. The pooled prevalence of AS was 39.1% (95% CI: 33.3-45.1) and was higher with skin test compared to specific IgE (43.8% vs. 32.8%, P = 0.002); however, the prevalence did not vary with the type of skin test used (intradermal or percutaneous). The prevalence of ABPA was 8.9% (95% CI: 7.4-10.7) and was higher in adults as compared to children (10.1% vs. 8.9%, P < 0.0001). There was a wide variation in the criteria used for diagnosing ABPA. Almost 50% (12/23) of the publications after 2004 used criteria other than the CF foundation criteria for diagnosing ABPA. There was significant statistical heterogeneity and evidence of publication bias. CONCLUSIONS There is a high prevalence of AS and ABPA in patients with CF. Despite six decades of research, there is still a need to adopt uniform methodology and criteria for the diagnosis of AS/ABPA.
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Affiliation(s)
- V N Maturu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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49
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Harun SN, Wainwright C, Klein K, Hennig S. A systematic review of studies examining the rate of lung function decline in patients with cystic fibrosis. Paediatr Respir Rev 2016; 20:55-66. [PMID: 27259460 DOI: 10.1016/j.prrv.2016.03.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 02/17/2016] [Accepted: 03/03/2016] [Indexed: 12/11/2022]
Abstract
A systematic review was performed (i) to describe the reported overall rate of progression of CF lung disease quantified as FEV1%predicted decline with age, (ii) to summarise identified influencing risk factors and (iii) to review methods used to analyse CF lung disease progression data. A search of publications providing FEV1%predicted values over age was conducted in PUBMED and EMBASE. Baseline and rate of FEV1%predicted decline were summarised overall and by identified risk factors. Thirty-nine studies were included and reported variable linear rates of lung function decline in patients with CF. The overall weighted mean FEV1%predicted over age was graphically summarised and showed a nonlinear, time-variant decline of lung function. Compared to their peers, Pseudomonas aeruginosa infection and pancreatic insufficiency were most commonly associated with lower baseline and more rapid FEV1%predicted declines respectively. Considering nonlinear models and drop-out in lung disease progression, analysis is lacking and more studies are warranted.
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Affiliation(s)
- Sabariah Noor Harun
- School of Pharmacy, The University of Queensland, Brisbane QLD 4072, Australia, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 USM, Pulau Pinang, Malaysia.
| | - Claire Wainwright
- Department of Respiratory and Sleep Medicine Lady Cilento Children's Hospital South Brisbane, Queensland 4101, Queensland Children's Medical Research Institute, Herston Rd, Herston QLD, 4029, and School of Medicine, The University of Queensland Brisbane, QLD 4072, Australia.
| | - Kerenaftali Klein
- Statistics/Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital QLD 4029 Australia.
| | - Stefanie Hennig
- School of Pharmacy, The University of Queensland, Brisbane QLD 4072, Australia.
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50
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Thronicke A, Heger N, Antweiler E, Krannich A, Roehmel J, Brandt C, Staab D, Tintelnot K, Schwarz C. Allergic bronchopulmonary aspergillosis is associated with pet ownership in cystic fibrosis. Pediatr Allergy Immunol 2016; 27:597-603. [PMID: 27145047 DOI: 10.1111/pai.12590] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Late diagnosis of allergic bronchopulmonary aspergillosis (ABPA) is associated with significant lung function decline and morbidity in cystic fibrosis (CF). The association of ABPA and domestic pet ownership in patients with CF has not been elucidated yet. Our objective was to determine the association of ABPA with pet ownership in patients with CF. METHODS Clinical and microbiological data from certified local patient registry were analyzed for 109 patients with CF aged 1-64 years: 55 pet owner and 54 non-pet owners. The primary outcome of the retrospective observational study was the occurrence of ABPA in pet owners and non-pet owners with CF. The free statistical software R was utilized to investigate logistic regression models for association factors. RESULTS Of the 109 patients included in the study, 61 (56%) were female. The mean age of the total group was 25.4 ± 13.2 years. Adjusted analysis revealed that ABPA (OR 5.0227, 95% CI: 1.182-21.340, p = 0.029) was associated with pet ownership in patients with CF. Furthermore, ABPA in pet owners with CF was associated with an increased number of exacerbations (OR 6.446, 95% CI: 1.057-39.328, p = 0.043). Other outcomes did not significantly differ. CONCLUSION Owning a pet was associated with ABPA in patients with CF. Future prospective multicenter longitudinal studies are needed to investigate chronological causality between pet ownership, ABPA development, and pulmonary exacerbations and to determine whether these estimates are generalizable for ABPA susceptible patients beyond CF (asthma, bronchiectasis).
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Affiliation(s)
- Anja Thronicke
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nikola Heger
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Elisabeth Antweiler
- Reference Laboratory for Cryptococcosis, Scedosporiosis and Imported Systemic Mycoses, FG16, Robert Koch Institute, Berlin, Germany
| | - Alexander Krannich
- Biostatistics Unit, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jobst Roehmel
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Brandt
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Doris Staab
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kathrin Tintelnot
- Reference Laboratory for Cryptococcosis, Scedosporiosis and Imported Systemic Mycoses, FG16, Robert Koch Institute, Berlin, Germany
| | - Carsten Schwarz
- Department of Pediatric Pneumology and Immunology, Cystic Fibrosis Center Berlin/Charité - Universitätsmedizin Berlin, Berlin, Germany
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