1
|
Cameron BH, Gong SW, Corry DB, Luong AU. Update on the Role of Fungus in Allergy, Asthma, and the Unified Airway. Otolaryngol Clin North Am 2024; 57:279-292. [PMID: 37867110 DOI: 10.1016/j.otc.2023.09.005] [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] [Indexed: 10/24/2023]
Abstract
The united airway refers to the combined upper and lower airways and their interconnected pathophysiologic relationships. Inflammatory airway diseases (chronic rhinosinusitis, asthma, and so forth) have been linked to fungal species through type 2 immune responses. These type 2 immune responses involve the cytokines interleukin (IL)-4, IL-5, IL-13, and a myriad of other inflammatory processes that lead to a spectrum of diseases from allergic bronchopulmonary mycosis to chronic rhinosinusitis. Historically, these diseases have been managed primarily with corticosteroids but recent revelations in the molecular pathophysiology provide opportunities for more diverse treatment options for patients with uncontrolled disease.
Collapse
Affiliation(s)
- Brian H Cameron
- Department of Otorhinolaryngology - Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin Street, MSB 5.036, Houston, TX, USA
| | - Shaina W Gong
- Department of Otorhinolaryngology - Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin Street, MSB 5.036, Houston, TX, USA
| | - David B Corry
- Department of Medicine, Biology of Inflammation Center, Baylor College of Medicine, One Baylor Plaza, Houston, 77030 TX, USA
| | - Amber U Luong
- Department of Otorhinolaryngology - Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin Street, MSB 5.036, Houston, TX, USA; Center for Immunology and Autoimmune Diseases, Institute of Molecular Medicine, 1835 Pressler, Houston, TX, 77030 USA.
| |
Collapse
|
2
|
Agarwal R, Sehgal IS, Muthu V, Denning DW, Chakrabarti A, Soundappan K, Garg M, Rudramurthy SM, Dhooria S, Armstrong-James D, Asano K, Gangneux JP, Chotirmall SH, Salzer HJF, Chalmers JD, Godet C, Joest M, Page I, Nair P, Arjun P, Dhar R, Jat KR, Joe G, Krishnaswamy UM, Mathew JL, Maturu VN, Mohan A, Nath A, Patel D, Savio J, Saxena P, Soman R, Thangakunam B, Baxter CG, Bongomin F, Calhoun WJ, Cornely OA, Douglass JA, Kosmidis C, Meis JF, Moss R, Pasqualotto AC, Seidel D, Sprute R, Prasad KT, Aggarwal AN. Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses. Eur Respir J 2024; 63:2400061. [PMID: 38423624 PMCID: PMC10991853 DOI: 10.1183/13993003.00061-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The International Society for Human and Animal Mycology (ISHAM) working group proposed recommendations for managing allergic bronchopulmonary aspergillosis (ABPA) a decade ago. There is a need to update these recommendations due to advances in diagnostics and therapeutics. METHODS An international expert group was convened to develop guidelines for managing ABPA (caused by Aspergillus spp.) and allergic bronchopulmonary mycosis (ABPM; caused by fungi other than Aspergillus spp.) in adults and children using a modified Delphi method (two online rounds and one in-person meeting). We defined consensus as ≥70% agreement or disagreement. The terms "recommend" and "suggest" are used when the consensus was ≥70% and <70%, respectively. RESULTS We recommend screening for A. fumigatus sensitisation using fungus-specific IgE in all newly diagnosed asthmatic adults at tertiary care but only difficult-to-treat asthmatic children. We recommend diagnosing ABPA in those with predisposing conditions or compatible clinico-radiological presentation, with a mandatory demonstration of fungal sensitisation and serum total IgE ≥500 IU·mL-1 and two of the following: fungal-specific IgG, peripheral blood eosinophilia or suggestive imaging. ABPM is considered in those with an ABPA-like presentation but normal A. fumigatus-IgE. Additionally, diagnosing ABPM requires repeated growth of the causative fungus from sputum. We do not routinely recommend treating asymptomatic ABPA patients. We recommend oral prednisolone or itraconazole monotherapy for treating acute ABPA (newly diagnosed or exacerbation), with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations. We have devised an objective multidimensional criterion to assess treatment response. CONCLUSION We have framed consensus guidelines for diagnosing, classifying and treating ABPA/M for patient care and research.
Collapse
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Kathirvel Soundappan
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Darius Armstrong-James
- Faculty of Medicine, Department of Infectious Disease, Imperial College London, London, UK
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Jean-Pierre Gangneux
- Université Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail), UMR_S 1085, Rennes, France
- CHU Rennes, Laboratoire de Parasitologie-Mycologie, ECMM Excellence Center in Medical Mycology, Rennes, France
- National Reference Center on Mycoses and Antifungals (CNRMA LA-Asp C), Rennes, France
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University (NTU) and Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Helmut J F Salzer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine-Pneumology, Kepler University Hospital and Medical Faculty, Johannes Kepler University, Linz, Austria
| | | | - Cendrine Godet
- Université Paris Sorbonne, AP-HP, Hôpital Tenon, Service de Pneumologie et Oncologie Thoracique, Centre Constitutif Maladies Pulmonaires Rares Paris, Paris, France
| | | | - Iain Page
- NHS Lothian, Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Parameswaran Nair
- McMaster University, McGill University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - P Arjun
- KIMS Hospital, Trivandrum, India
| | - Raja Dhar
- Department of Pulmonology, CK Birla Hospitals, Kolkata, India
| | - Kana Ram Jat
- Division of Pediatric Pulmonology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Joseph L Mathew
- Pediatric Pulmonology Division, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Nath
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute, Lucknow, India
| | - Dharmesh Patel
- City Clinic and Bhailal Amin General Hospital, Vadodara, India
| | - Jayanthi Savio
- Department of Microbiology, St John's Medical College and Hospital, Bengaluru, India
| | - Puneet Saxena
- Pulmonary and Critical Care Medicine, Army Hospital (R&R), New Delhi, India
| | - Rajeev Soman
- Department of Infectious Diseases, Jupiter Hospital, Pune, India
| | | | - Caroline G Baxter
- Department of Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - William J Calhoun
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Oliver A Cornely
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
| | - Jo A Douglass
- University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
| | - Chris Kosmidis
- Division of Evolution, Infection and Genomics, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jacques F Meis
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
- Center of Expertise in Mycology Radboudumc/CWZ Nijmegen, Nijmegen, The Netherlands
| | - Richard Moss
- Center of Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Alessandro C Pasqualotto
- Molecular Biology Laboratory, Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Danila Seidel
- Department of Internal Medicine, University Hospital, Cologne, Germany
| | - Rosanne Sprute
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
3
|
Agarwal R, Muthu V, Sehgal IS. Clinical Manifestation and Treatment of Allergic Bronchopulmonary Aspergillosis. Semin Respir Crit Care Med 2024; 45:114-127. [PMID: 38154470 DOI: 10.1055/s-0043-1776912] [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: 12/30/2023]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction to airway colonization by Aspergillus fumigatus in patients with asthma and cystic fibrosis. The pathophysiology of ABPA involves a complex interplay between the fungus and the host immune response, which causes persistent inflammation and tissue damage. Patients present with chronic cough, wheezing, and dyspnea due to uncontrolled asthma. Characteristic symptoms include the expectoration of brownish mucus plugs. Radiographic findings often reveal fleeting pulmonary infiltrates, bronchiectasis, and mucus impaction. However, the definitive diagnosis of ABPA requires a combination of clinical, radiological, and immunological findings. The management of ABPA aims to reduce symptoms, prevent disease progression, and minimize the future risk of exacerbations. The treatment approach involves systemic glucocorticoids or antifungal agents to suppress the inflammatory response or fungal growth and prevent exacerbations. Biological agents may be used in patients with severe disease or glucocorticoid dependence. This review provides an overview of the clinical manifestations and current treatment options for ABPA.
Collapse
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
4
|
Denning DW, Pfavayi LT. Poorly controlled asthma - Easy wins and future prospects for addressing fungal allergy. Allergol Int 2023; 72:493-506. [PMID: 37544851 DOI: 10.1016/j.alit.2023.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 08/08/2023] Open
Abstract
Poorly controlled asthma is especially common in low resource countries. Aside from lack of access to, or poor technique with, inhaled beta-2 agonists and corticosteroids, the most problematic forms of asthma are frequently associated with both fungal allergy and exposure, especially in adults leading to more asthma exacerbations and worse asthma. The umbrella term 'fungal asthma' describes many disorders linked to fungal exposure and/or allergy to fungi. One fungal asthma endotype, ABPA, is usually marked by a very high IgE and its differential diagnosis is reviewed. Both ABPA and fungal bronchitis in bronchiectasis are marked by thick excess airway mucus production. Dermatophyte skin infection can worsen asthma and eradication of the skin infection improves asthma. Exposure to fungi in the workplace, home and schools, often in damp or water-damaged buildings worsens asthma, and remediation improves symptom control and reduces exacerbations. Antifungal therapy is beneficial for fungal asthma as demonstrated in nine of 13 randomised controlled studies, reducing symptoms, corticosteroid need and exacerbations while improving lung function. Other useful therapies include azithromycin and some biologics approved for the treatment of severe asthma. If all individuals with poorly controlled and severe asthma could be 'relieved' of their fungal allergy and infection through antifungal therapy without systemic corticosteroids, the health benefits would be enormous and relatively inexpensive, improving the long term health of over 20 million adults and many children. Antifungal therapy carries some toxicity, drug interactions and triazole resistance risks, and data are incomplete. Here we summarise what is known and what remains uncertain about this complex topic.
Collapse
Affiliation(s)
- David W Denning
- Manchester Fungal Infection Group, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK.
| | - Lorraine T Pfavayi
- Institute of Immunology & Infection Research, Ashworth Laboratories, School of Biological Sciences, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
5
|
Agarwal R, Muthu V, Sehgal IS. Relationship between Aspergillus and asthma. Allergol Int 2023; 72:507-520. [PMID: 37633774 DOI: 10.1016/j.alit.2023.08.004] [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: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/28/2023] Open
Abstract
Fungal sensitization is highly prevalent in severe asthma. The relationship between fungus and asthma, especially Aspergillus fumigatus, has been the subject of extensive research. The ubiquitous presence of A. fumigatus, its thermotolerant nature, the respirable size of its conidia, and its ability to produce potent allergens are pivotal in worsening asthma control. Due to the diverse clinical manifestations of fungal asthma and the lack of specific biomarkers, its diagnosis remains intricate. Diagnosing fungal asthma requires carefully assessing the patient's clinical history, immunological tests, and imaging. Depending on the severity, patients with fungal asthma require personalized treatment plans, including inhaled corticosteroids and bronchodilators, and antifungal therapy. This review provides a comprehensive overview of the association between Aspergillus and asthma by reviewing the relevant literature and highlighting key findings. We discuss the diagnosis of various entities included in fungal asthma. We also debate whether newer definitions, including allergic fungal airway disease, offer any additional advantages over the existing ones. Finally, we provide the current treatment options for the individual entities, including A. fumigatus-associated asthma, severe asthma with fungal sensitization, and allergic bronchopulmonary mycoses.
Collapse
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
6
|
Khan J, Moran B, McCarthy C, Butler MW, Franciosi AN. Management of comorbidities in difficult and severe asthma. Breathe (Sheff) 2023; 19:230133. [PMID: 38020342 PMCID: PMC10644109 DOI: 10.1183/20734735.0133-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Difficult-to-treat and severe asthma are challenging clinical entities. In the face of suboptimal asthma control, the temptation for clinicians is to reflexively escalate asthma-directed therapy, including increasing exposure to corticosteroids and commencement of costly but potent biologic therapies. However, asthma control is objectively and subjectively assessed based on measurable parameters (such as exacerbations or variability in pulmonary physiology), symptoms and patient histories. Crucially, these features can be confounded by common untreated comorbidities, affecting clinicians' assessment of asthma treatment efficacy.
Collapse
Affiliation(s)
- Jehangir Khan
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
- Shared first authorship
| | - Barry Moran
- St Vincent's University Hospital, Dublin, Ireland
- Shared first authorship
| | - Cormac McCarthy
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
| | - Marcus W. Butler
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
- Shared senior authorship
| | - Alessandro N. Franciosi
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
- Shared senior authorship
| |
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
Hamada T, Katsuta T, Aibara K, Nozu S, Nakamura J, Kondo H, Tachibana S, Inoue K, Nakanishi N, Moritaka T. Mepolizumab in allergic bronchopulmonary aspergillosis complicated by infection. Respir Med Case Rep 2023; 45:101890. [PMID: 37560613 PMCID: PMC10407267 DOI: 10.1016/j.rmcr.2023.101890] [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: 05/02/2023] [Revised: 06/10/2023] [Accepted: 07/03/2023] [Indexed: 08/11/2023] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is an allergic reaction caused by the fungus Aspergillus, and it is often treated with steroids or antifungal agents. However, long-term use of these medications can lead to infections and drug interactions. We present the case of a 71-year-old woman with ABPA who was diagnosed with hepatitis B and active hepatitis C, and sputum analysis revealed the presence of bacteria. Oral steroids were initially administered, but the patient was switched to mepolizumab because of numerous infectious complications. The early introduction of mepolizumab is effective in patients with ABPA complicated by infectious diseases.
Collapse
Affiliation(s)
- Toru Hamada
- Respiratory Medicine, Ehime Prefectural Central Hospital, Matsuyama, Ehime, 790-0024, Japan
| | - Tomoya Katsuta
- Respiratory Medicine, Ehime Prefectural Central Hospital, Matsuyama, Ehime, 790-0024, Japan
| | - Kento Aibara
- Respiratory Medicine, Ehime Prefectural Central Hospital, Matsuyama, Ehime, 790-0024, Japan
| | - Shohei Nozu
- Respiratory Medicine, Ehime Prefectural Central Hospital, Matsuyama, Ehime, 790-0024, Japan
| | - Junya Nakamura
- Respiratory Medicine, Ehime Prefectural Central Hospital, Matsuyama, Ehime, 790-0024, Japan
| | - Haruka Kondo
- Respiratory Medicine, Ehime Prefectural Central Hospital, Matsuyama, Ehime, 790-0024, Japan
| | - Sayaka Tachibana
- Respiratory Medicine, Ehime Prefectural Central Hospital, Matsuyama, Ehime, 790-0024, Japan
| | - Koji Inoue
- Respiratory Medicine, Ehime Prefectural Central Hospital, Matsuyama, Ehime, 790-0024, Japan
| | - Norihiko Nakanishi
- Respiratory Medicine, Ehime Prefectural Central Hospital, Matsuyama, Ehime, 790-0024, Japan
| | - Tomonori Moritaka
- Respiratory Medicine, Ehime Prefectural Central Hospital, Matsuyama, Ehime, 790-0024, Japan
| |
Collapse
|
9
|
Bergagnini-Kolev M, Kane K, Templeton IE, Curran AK. Evaluation of the Potential for Drug-Drug Interactions with Inhaled Itraconazole Using Physiologically Based Pharmacokinetic Modelling, Based on Phase 1 Clinical Data. AAPS J 2023; 25:62. [PMID: 37344751 DOI: 10.1208/s12248-023-00828-z] [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: 03/08/2023] [Accepted: 06/02/2023] [Indexed: 06/23/2023] Open
Abstract
Itraconazole is a potent inhibitor of cytochrome P450 3A4 (CYP3A4), associated with numerous drug-drug interactions (DDI). PUR1900, a dry powder formulation of itraconazole for oral inhalation, results in high lung and low systemic exposure. This project used physiologically based pharmacokinetic (PBPK) modeling to assess the DDI potential of inhaled PUR1900, using midazolam as a "victim drug." The basic and mechanistic static models evaluated the DDI potential of PUR1900, assuming 5 mg of midazolam coadministration at steady-state itraconazole exposure. Subsequently, Simcyp® PBPK simulation software and pharmacokinetic data from a Phase 1 clinical trial with PUR1900 (NCT03479411) were used to optimize an existing itraconazole PBPK model. The model was applied to investigate the potential for CYP3A4 DDI when 5 mg of midazolam is co-administered with inhaled PUR1900 at a steady state in a virtual healthy population at PUR1900 doses up to 40 mg per day. The basic static and mechanistic static models suggested a strong likelihood for DDI with inhaled PUR1900. The PBPK model was consistent with PUR1900 Phase 1 trial data. The geometric mean Cmax and AUC ratios of midazolam at a maximum dose of 40 mg PUR1900 were 1.14 and 1.26, respectively, indicating a minimal likelihood of DDI with inhaled PUR1900. The low systemic exposure of itraconazole when administered as PUR1900 results in minimal to no CYP3A4 inhibition, reducing the concern of drug-drug interactions. As the risk of CYP3A4 DDI is predicted to be significantly lower when itraconazole is administered via oral inhalation as PUR1900, it is likely that PUR1900 can be safely used for the treatment of pulmonary fungal infections in patients taking pharmaceuticals currently contraindicated with oral itraconazole.
Collapse
Affiliation(s)
| | - Katie Kane
- Pulmatrix, Inc, 36 Crosby Drive, Suite 100, Bedford, MA, 01730, USA
| | | | - Aidan K Curran
- Pulmatrix, Inc, 36 Crosby Drive, Suite 100, Bedford, MA, 01730, USA.
| |
Collapse
|
10
|
Salil A, Joy N, Faizal B. A prospective study comparing itraconazole alone versus systemic steroids alone as adjuncts to topical steroids in the post-operative management of allergic fungal rhinosinusitis. Clin Otolaryngol 2023; 48:356-362. [PMID: 36478077 DOI: 10.1111/coa.14014] [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: 06/01/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The objective of this study was to compare the efficacy of itraconazole and systemic steroids as an adjuvant to topical steroids in post-operative patients with allergic fungal rhinosinusitis (AFRS) using both subjective and objective outcome measurements. DESIGN A prospective comparative study. SETTING A tertiary care centre. PARTICIPANTS Sixty patients diagnosed with AFRS were included. Patients with chronic systemic illness and those undergoing revision surgery were excluded. Post-operative patients were divided into two groups of 30 each which received itraconazole 400 mg OD or methylprednisolone in tapering doses over 6 weeks. MAIN OUTCOME MEASURES The outcomes were measured at the end of 6 weeks-Kupferberg endoscopic staging, absolute eosinophilic count (AEC), serum immunoglobulin (IgE), and Sino Nasal Outcome Test-20 scores. RESULTS Our study showed no statistical significance in outcomes between the two groups treated with itraconazole and methylprednisolone regarding recurrence, AEC, IgE and quality of life assessment (p < 0.01). CONCLUSION Itraconazole was comparable to methylprednisolone in preventing disease recurrence in the post-operative management of AFRS. It may be a viable alternative to replacing systemic steroids where the latter may be contraindicated. Itraconazole given at a dose of 400 mg once daily for 6 weeks was a safe dose.
Collapse
Affiliation(s)
- Amala Salil
- Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - Nedha Joy
- Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| | - Bini Faizal
- Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeedham University, Kochi, India
| |
Collapse
|
11
|
Systemic Antifungal Therapy for Invasive Pulmonary Infections. J Fungi (Basel) 2023; 9:jof9020144. [PMID: 36836260 PMCID: PMC9966409 DOI: 10.3390/jof9020144] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
Antifungal therapy for pulmonary fungal diseases is in a state of flux. Amphotericin B, the time-honored standard of care for many years, has been replaced by agents demonstrating superior efficacy and safety, including extended-spectrum triazoles and liposomal amphotericin B. Voriconazole, which became the treatment of choice for most pulmonary mold diseases, has been compared with posaconazole and itraconazole, both of which have shown clinical efficacy similar to that of voriconazole, with fewer adverse events. With the worldwide expansion of azole-resistant Aspergillus fumigatus and infections with intrinsically resistant non-Aspergillus molds, the need for newer antifungals with novel mechanisms of action becomes ever more pressing.
Collapse
|
12
|
Moss RB. Severe Fungal Asthma: A Role for Biologics and Inhaled Antifungals. J Fungi (Basel) 2023; 9:jof9010085. [PMID: 36675906 PMCID: PMC9861760 DOI: 10.3390/jof9010085] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
Allergic asthma has traditionally been treated with inhaled and systemic glucocorticosteroids. A continuum of allergic fungal airways disease associated with Aspergillus fumigatus colonization and/or atopic immune responses that encompasses fungal asthma, severe asthma with fungal sensitization and allergic bronchopulmonary aspergillosis is now recognized along a phenotypic severity spectrum of T2-high immune deviation lung disease. Oral triazoles have shown clinical, anti-inflammatory and microbiologic efficacy in this setting; in the future inhaled antifungals may improve the therapeutic index. Humanized monoclonal antibody biologic agents targeting T2-high disease also show efficacy and promise of improved control in difficult cases. Developments in these areas are highlighted in this overview.
Collapse
Affiliation(s)
- Richard B Moss
- Center of Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University School of Medicine, 770 Welch Road, Suite 350, Palo Alto, CA 94304, USA
| |
Collapse
|
13
|
Asano K, Suzuki Y, Tanaka J, Kobayashi K, Kamide Y. Treatments of refractory eosinophilic lung diseases with biologics. Allergol Int 2023; 72:31-40. [PMID: 36333218 DOI: 10.1016/j.alit.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022] Open
Abstract
Biologics targeting the molecules associated with type 2 inflammation have significantly improved the outcomes of patients with severe eosinophilic asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). Chronic eosinophilic airway/lung diseases including chronic eosinophilic pneumonia, allergic bronchopulmonary aspergillosis/mycosis, eosinophilic bronchitis, and eosinophilic granulomatosis with polyangiitis share clinical features with eosinophilic asthma and CRPwNP, which are mostly adult-onset and may develop simultaneously or consecutively. These eosinophilic airway/lung diseases respond well to initial treatment with systemic corticosteroids, but often recur when the corticosteroids are tapered. The management of these "refractory" cases is an unmet need for clinicians. We first reviewed the standard treatments for these chronic eosinophilic airway/lung diseases, followed by the definition and prevalence of refractory diseases and the role of biologics in their management. The available evidence varies from case reports and case series to randomized control trials, depending on the type of disease; however, these studies provide not only a direction for clinical practice, but also insights into the pathophysiology of each disease. Physicians should discuss the efficacy and costs of biologics in patients with refractory eosinophilic airway/lung diseases to minimize not only the current symptoms, but future risks as well.
Collapse
Affiliation(s)
- Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
| | - Yuzo Suzuki
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Jun Tanaka
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Konomi Kobayashi
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yosuke Kamide
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Japan
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
An Interesting Case of Allergic Bronchopulmonary Aspergillosis Resulting in Type II Respiratory Failure. JOURNAL OF RESPIRATION 2022. [DOI: 10.3390/jor3010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Aspergillus fumigatus can cause an immunological hypersensitivity reaction known as allergic bronchopulmonary aspergillosis (ABPA), which often worsens asthma and cystic fibrosis patients’ conditions. In India, where tuberculosis (TB) is endemic, a significant proportion of allergic bronchopulmonary aspergillosis (ABPA) patients are misdiagnosed as pulmonary TB before reaching a diagnosis of ABPA due to long-lasting symptoms. We discuss an uncommon presentation of ABPA with type II respiratory failure in a 48-year-old asthmatic female. Given this, one can speculate on the importance of ABPA presenting with respiratory failure since these cases are rare and diagnosed quite late, which can also prove fatal.
Collapse
|
16
|
Fanta CH. Advances in Evaluation and Treatment of Severe Asthma (Part One). Med Clin North Am 2022; 106:971-986. [PMID: 36280340 DOI: 10.1016/j.mcna.2022.08.003] [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] [Indexed: 11/15/2022]
Abstract
As many as 15% to 20% of patients with asthma have incompletely or poorly controlled asthma despite treatment with inhaled corticosteroids and long-acting beta-agonist bronchodilators. They are vulnerable to burdensome symptoms, limitations to their exercise capacity, and asthma attacks that can be frightening and potentially life-threatening. This article outlines a systematic approach to their evaluation, attempting to identify remediable factors that are making their asthma more severe than most other persons with asthma. This approach includes an emphasis on ensuring the correct diagnosis, minimizing exposures to stimuli that worsen airway inflammation, alleviating modifiable comorbidities such as chronic rhinosinusitis and gastroesophageal reflux, and supporting regular medication adherence and effective technique for administering inhaled medications. A basic diagnostic laboratory work-up is recommended, to be modified and amplified according to individual patient needs.
Collapse
Affiliation(s)
- Christopher H Fanta
- Partners Asthma Center, Pulmonary and Critical Care Medicine Division, Brigham and Women's Hospital, Harvard Medical School, PBB - Clinics 3, 75 Francis Street, Boston, MA 02115, USA.
| |
Collapse
|
17
|
Francis NZ, Southern KW. Antifungal therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database Syst Rev 2022; 9:CD002204. [PMID: 36053129 PMCID: PMC9438469 DOI: 10.1002/14651858.cd002204.pub5] [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: 11/08/2022]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is an allergic reaction to colonisation of the lungs with the fungus Aspergillus fumigatus, and affects around 10% of people with cystic fibrosis. ABPA is associated with an accelerated decline in lung function. High doses of corticosteroids are the main treatment for ABPA; although the long-term benefits are not clear, and their many side effects are well-documented. A group of compounds, the azoles, have activity against A fumigatus, and have been proposed as an alternative treatment for ABPA. Of this group, itraconazole is the most active. A separate antifungal compound, amphotericin B, has been used in aerosolised form to treat invasive infection with A fumigatus, and may have potential for the treatment of ABPA. Antifungal therapy for ABPA in cystic fibrosis needs to be evaluated. This is an update of a previously published review. OBJECTIVES The review aimed to test the hypotheses that antifungal interventions for the treatment of ABPA in cystic fibrosis: 1. improve clinical status compared to placebo or standard therapy (no placebo); and 2. do not have unacceptable adverse effects. If benefit was demonstrated, we planned to assess the optimal type, duration, and dose of antifungal therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals, and abstract books of conference proceedings. Date of the most recent search of the Group's Trials Register was 28 September 2021. We searched ongoing trials registries, most recently on 11 March 2022. Earlier, we also approached pharmaceutical companies regarding possible unpublished trials. SELECTION CRITERIA Published or unpublished randomised controlled trials, in which antifungal treatments were compared to either placebo or no treatment, or where different doses of the same treatment were used in the treatment of ABPA in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS The searches identified six trials; none of which met the inclusion criteria for the review. MAIN RESULTS We included no completed randomised controlled trials. There is currently one ongoing trial, which we may find eligible for a future update. AUTHORS' CONCLUSIONS At present, there are no randomised controlled trials that evaluate the use of antifungal therapies for the treatment of ABPA in people with cystic fibrosis, although one trial is currently ongoing. Trials with clear outcome measures are needed to properly evaluate the use of corticosteroids in people with ABPA and cystic fibrosis.
Collapse
Affiliation(s)
- Natalie Z Francis
- Manchester Adult Cystic Fibrosis Centre, University of Manchester, Manchester, UK
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| |
Collapse
|
18
|
Gaffin JM, Castro M, Bacharier LB, Fuhlbrigge AL. The Role of Comorbidities in Difficult-to-Control Asthma in Adults and Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:397-408. [PMID: 34863928 PMCID: PMC8837696 DOI: 10.1016/j.jaip.2021.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/29/2021] [Accepted: 11/22/2021] [Indexed: 02/07/2023]
Abstract
Assessment of asthma comorbidities, conditions that adversely affect the pathobiology of asthma or impair its response to therapies, is a fundamental step in the evaluation and management of patients with difficult-to-treat asthma. Identifying and effectively treating asthma comorbidities, such as obesity, obstructive sleep apnea, and chronic sinusitis with nasal polyps, may improve asthma control and reduce exacerbations. In addition, identifying comorbid T2 inflammatory conditions may help guide optimal selection of biologic therapies. Here, we describe common comorbid conditions found in adult and pediatric difficult-to-control asthma, discuss evidence for the association with asthma morbidity and treatment benefit, and provide information on how and when to assess comorbidities.
Collapse
Affiliation(s)
- Jonathan M. Gaffin
- Division of Pulmonary Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston MA, USA
| | - Mario Castro
- Division of Pulmonary, Critical Care Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Leonard B. Bacharier
- Division of Pediatric Allergy, Immunology and Pulmonary Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Anne L. Fuhlbrigge
- Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
19
|
The Use of Targeted Monoclonal Antibodies in the Treatment of ABPA—A Case Series. Medicina (B Aires) 2021; 58:medicina58010053. [PMID: 35056359 PMCID: PMC8780696 DOI: 10.3390/medicina58010053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/24/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder occurring in response to Aspergillus fumigatus that can complicate the course of asthma and cystic fibrosis. Here we present a case of acute ABPA without central bronchiectasis, a case of chronic active ABPA with central bronchiectasis, and a case of severe relapsing ABPA with central bronchiectasis. All three were initially treated with corticosteroids and antifungal agents but had an incomplete response. These patients were then treated with anti-IgE therapy with omalizumab before being switched to the anti-IL5R agent benralizumab. They responded well to both agents. These case reports highlight the potential role of omalizumab and benralizumab in the treatment of ABPA, but further studies are required to evaluate the effectiveness of these medications. Longer follow-up periods and objective measurements of the impact of treatment are necessary.
Collapse
|
20
|
Agarwal R, Muthu V. Prednisolone plus itraconazole in acute-stage allergic bronchopulmonary aspergillosis complicating asthma. Eur Respir J 2021; 59:13993003.02989-2021. [PMID: 34887329 DOI: 10.1183/13993003.02989-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/28/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
21
|
Havette A, Regard L, Roche N, Burgel PR. Prednisolone plus itraconazole in acute-stage allergic bronchopulmonary aspergillosis complicating asthma: is the benefit worth the risk? Eur Respir J 2021; 59:13993003.02924-2021. [PMID: 34887327 DOI: 10.1183/13993003.02924-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Alice Havette
- Service de Pneumologie, Hôpital Cochin, AP-HP, Paris, France.,These authors equally contributed
| | - Lucile Regard
- Service de Pneumologie, Hôpital Cochin, AP-HP, Paris, France.,Institut Cochin and Université de Paris, INSERM U1016, Paris, France.,These authors equally contributed
| | - Nicolas Roche
- Service de Pneumologie, Hôpital Cochin, AP-HP, Paris, France.,Institut Cochin and Université de Paris, INSERM U1016, Paris, France
| | - Pierre-Régis Burgel
- Service de Pneumologie, Hôpital Cochin, AP-HP, Paris, France .,Institut Cochin and Université de Paris, INSERM U1016, Paris, France
| |
Collapse
|
22
|
Delcros Q, Groh M, Nasser M, Kahn JE, Cottin V. Steroid alternatives for managing eosinophilic lung diseases. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.2003777] [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: 10/19/2022]
Affiliation(s)
- Quentin Delcros
- National Reference Center for Hypereosinophilic Syndrome (Cereo)
- Department of Internal Medicine Hôpital Foch, Suresnes, France
| | - Matthieu Groh
- National Reference Center for Hypereosinophilic Syndrome (Cereo)
- Department of Internal Medicine Hôpital Foch, Suresnes, France
| | - Mouhamad Nasser
- Department of Respiratory Medicine, National Coordinating Reference Centre for Rare Pulmonary Diseases (Orphalung), Louis Pradel Hospital, Hospices Civils De Lyon, and Claude Bernard University Lyon 1, IVPC, Member of OrphaLung, RespiFIL and ERN-lung, France
| | - Jean-Emmanuel Kahn
- National Reference Center for Hypereosinophilic Syndrome (Cereo)
- Department of Internal Medicine, Hôpital Ambroise Paré, Université Paris Saclay, Assistance Publique Hôpitaux De Paris, Boulogne-Billancourt, France
| | - Vincent Cottin
- Department of Respiratory Medicine, National Coordinating Reference Centre for Rare Pulmonary Diseases (Orphalung), Louis Pradel Hospital, Hospices Civils De Lyon, and Claude Bernard University Lyon 1, IVPC, Member of OrphaLung, RespiFIL and ERN-lung, France
| |
Collapse
|
23
|
Godet C, Couturaud F, Marchand-Adam S, Pison C, Gagnadoux F, Blanchard E, Taillé C, Philippe B, Hirschi S, Andréjak C, Bourdin A, Chenivesse C, Dominique S, Bassinet L, Murris-Espin M, Rivière F, Garcia G, Caillaud D, Blanc FX, Goupil F, Bergeron A, Gondouin A, Frat JP, Flament T, Camara B, Priou P, Brun AL, Laurent F, Ragot S, Cadranel J. Nebulised liposomal-amphotericin-B as maintenance therapy in ABPA: a randomised, multicentre, trial. Eur Respir J 2021; 59:13993003.02218-2021. [PMID: 34764182 DOI: 10.1183/13993003.02218-2021] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/21/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND In allergic bronchopulmonary aspergillosis (ABPA), prolonged nebulised antifungal treatment may be a strategy for maintaining remission. METHODS We performed a randomised, single-blind, clinical trial in 30 centres. Patients with controlled ABPA after a 4-month attack treatment (corticosteroids and itraconazole) were randomly assigned to nebulised liposomal-amphotericin-B or placebo for 6 months. The primary outcome was occurrence of a first severe clinical exacerbation within 24 months following randomisation. Secondary outcomes included the median time-to-first severe clinical exacerbation, number of severe clinical exacerbations per patient, ABPA-related biological parameters. RESULTS Among 174 enrolled patients with ABPA from March 2015 through July 2017, 139 were controlled after 4-month attack treatment and were randomised. The primary outcome occurred in 33 (50.8%) of 65 patients in nebulised liposomal-amphotericin-B group and 38 (51.3%) of 74 in placebo group (absolute difference -0.6%, 95% CI -16.8% to +15.6%, odds ratio 0.98, 95% CI 0.50 to 1.90; p=0.95). The median time-to-first severe clinical exacerbation was longer in liposomal-amphotericin-B group, 337 days (IQR, 168 to 476) versus 177 (64 to 288). At the end of maintenance therapy, total immunoglobulin-E and Aspergillus precipitins were significantly decreased in nebulised liposomal-amphotericin-B group. CONCLUSIONS In ABPA, maintenance therapy using nebulised liposomal-amphotericin-B did not reduce the risk of severe clinical exacerbation. The presence of some positive secondary outcomes creates clinical equipoise for further research.
Collapse
Affiliation(s)
- Cendrine Godet
- Service de Pneumologie, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Sylvain Marchand-Adam
- Université François Rabelais, Inserm, Tours, France.,service de pneumologie et explorations fonctionnelles respiratoires, CHRU de Tours, Tours, France
| | - Christophe Pison
- CHU Grenoble Alpes, Service Hospitalier Universitaire Pneumologie Physiologie, Université Grenoble Alpes, Grenoble, France
| | - Frédéric Gagnadoux
- Département de Pneumologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | | | - Camille Taillé
- Service de Pneumologie, Groupe Hospitalier Universitaire AP-HP Nord-Université de Paris, Hôpital Bichat, et Centre de Référence constitutif des Maladies Pulmonaires Rares, Paris, France
| | - Bruno Philippe
- Service de Pneumologie, Hôpital René Dubos, Pontoise, France
| | - Sandrine Hirschi
- Service de Pneumologie, Hôpitaux Universitaires de Strasbourg, Centre de Compétence des Maladies Pulmonaires Rares, Strasbourg, France
| | - Claire Andréjak
- Service de Pneumologie, CHU Amiens Picardie, Université de Picardie Jules Verne, Amiens, France
| | - Arnaud Bourdin
- Université de Montpellier, CHU Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Cécile Chenivesse
- Service de Pneumologie et Immuno-allergologie, CHU Lille, Centre de référence constitutif pour les maladies pulmonaires rares, Lille, France; University Lille, Inserm UMR9017, Institut Pasteur de Lille, CIIL - Centre d'Infection et d'Immunité de Lille, Lille, France, CRISALIS/F-CRIN INSERM network
| | | | | | - Marlène Murris-Espin
- Service de Pneumologie, CHU de Toulouse, CRCM adulte et Transplantation pulmonaire. Clinique des Voies Respiratoires, Hôpital Larrey, Toulouse, France
| | - Frédéric Rivière
- Service de Pneumologie, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Gilles Garcia
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,"Pulmonary Hypertension: Pathophysiology and Novel Therapies", INSERM UMR-S 999 Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Department of Respiratory and Intensive Care Medicine, Assistance Publique - Hôpitaux de Paris, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Denis Caillaud
- Service de Pneumologie-Allergologie, CHU Gabriel Montpied, Clermont Auvergne University, Clermont-Ferrand, France
| | - François-Xavier Blanc
- Service de Pneumologie et centre d'investigations cliniques Thorax, CHU de Nantes, Nantes, France
| | | | - Anne Bergeron
- Service de Pneumologie, Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Anne Gondouin
- Service de pneumologie, CHU Besançon, Besançon, France
| | - Jean-Pierre Frat
- CHU Poitiers, Médecine Intensive Réanimation, Poitiers, France; Inserm, CIC, Université de Poitiers, France
| | - Thomas Flament
- service de pneumologie et explorations fonctionnelles respiratoires, CHRU de Tours, Tours, France
| | - Boubou Camara
- CHU Grenoble Alpes, Service Hospitalier Universitaire Pneumologie Physiologie, Université Grenoble Alpes, Grenoble, France
| | - Pascaline Priou
- Département de Pneumologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | | | - François Laurent
- Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, , Bordeaux, France.,Service d'Imagerie diagnostique et thérapeutique-Groupe Hospitalier Sud, CHU de Bordeaux, Pessac, France
| | - Stéphanie Ragot
- Faculté de Médecine et de Pharmacie de Poitiers, INSERM, CIC-1402, Biostatistics, Poitiers, France; Université de Poitiers, Poitiers, France
| | - Jacques Cadranel
- Service de Pneumologie, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | | |
Collapse
|
24
|
Lewington-Gower E, Chan L, Shah A. Review of current and future therapeutics in ABPA. Ther Adv Chronic Dis 2021; 12:20406223211047003. [PMID: 34729149 PMCID: PMC8543630 DOI: 10.1177/20406223211047003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/26/2021] [Indexed: 12/17/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis is an allergic pulmonary condition caused by hypersensitivity to antigens of Aspergillus sp. found most commonly in patients with underlying asthma or cystic fibrosis. Host factors which alter the innate and adaptive immune responses to this abundant airborne fungus contribute to the development of chronic airway inflammation, bronchiectasis, and fibrosis. Traditionally, treatment has focussed on reducing fungal burden and immune response to fungal antigens. However, a significant proportion of patients continue to suffer recurrent exacerbations with progressive lung damage, and the side effect burden of existing treatments is high. New treatments including novel antifungal agents, monoclonal antibodies against aspects of the adaptive immune response as well as targeted immunotherapies may be better tolerated and achieve improved outcomes but have not yet been studied in large-scale randomised control trials.
Collapse
Affiliation(s)
- Elisa Lewington-Gower
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Ley Chan
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Anand Shah
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| |
Collapse
|
25
|
Agarwal R, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Garg M, Aggarwal AN, Chakrabarti A. A randomised trial of prednisolone versus prednisolone and itraconazole in acute-stage allergic bronchopulmonary aspergillosis complicating asthma. Eur Respir J 2021; 59:13993003.01787-2021. [PMID: 34503983 DOI: 10.1183/13993003.01787-2021] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/29/2021] [Indexed: 11/05/2022]
Abstract
Whether a combination of glucocorticoid and antifungal triazole is superior to glucocorticoid alone, in reducing exacerbations, in patients with allergic bronchopulmonary aspergillosis (ABPA) remains unknown. We aimed to compare the efficacy and safety of prednisolone-itraconazole combination versus prednisolone monotherapy in ABPA.We randomised subjects with treatment-naïve acute-stage ABPA complicating asthma to receive either prednisolone alone (four months) or a combination of prednisolone and itraconazole (four and six months, respectively). The primary outcomes were exacerbation rates at 12 months and glucocorticoid-dependent ABPA within 24 months of initiating treatment. The key secondary outcomes were response rates and percentage decline in serum total IgE at six weeks, time to first ABPA exacerbation, and treatment-emergent adverse effects (AE).We randomised 191 subjects to receive either prednisolone (n=94) or prednisolone-itraconazole combination (n=97). The one-year exacerbation rate was 33% and 20.6% in the prednisolone and the prednisolone-itraconazole arms, respectively (p=0.054). None of the participants progressed to glucocorticoid-dependent ABPA. All the subjects experienced a composite response at 6-weeks, along with a decline in serum total IgE (mean decline, 47.6% versus 45.5%). The mean time to first ABPA exacerbation (417 days) was not different between the groups. None of the participants required modification of therapy due to AE.There was a trend towards a decline in ABPA exacerbations at 1-year with the prednisolone-itraconazole combination than prednisolone monotherapy. A three-arm trial comparing itraconazole and prednisolone monotherapies with their combination, preferably in a multicentric design, is required to define the best treatment strategy for acute-stage ABPA.
Collapse
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
26
|
Hong G, Desai S, Moss RB, Eschenhagen P, Quon BS, Schwarz C. Clinician variability in the diagnosis and treatment of aspergillus fumigatus-related conditions in cystic fibrosis: An international survey. J Cyst Fibros 2021; 21:136-142. [PMID: 34332906 DOI: 10.1016/j.jcf.2021.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/07/2021] [Accepted: 07/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The diagnosis and treatment of Aspergillus fumigatus (Af)-related conditions remain a challenge in cystic fibrosis (CF) due to overlapping features of disease and absence of clinical guidelines for Af-related conditions outside of ABPA. OBJECTIVE To investigate the differences of clinical practice in the diagnosis and management of Af-related conditions in CF. METHODS We conducted an international survey to CF clinicians to ascertain the screening, diagnostic, and treatment practices for Af-related conditions in CF. Respondents were grouped into geographical regions and regional comparisons using chi-square tests of independence or Fisher's tests were performed. RESULTS A total of 319 survey responses from 35 countries were analyzed. We observed differences in use and frequency of fungus culture, Aspergillus-specific IgE and IgG, skin prick testing, and pulmonary function testing as screening for Af-related conditions between the geographical regions. ABPA and Aspergillus bronchitis diagnostic criteria selection differed by region; significantly greater proportion of United States (US) and Canadian clinicians were unable to define Aspergillus bronchitis compared to Europe and other regions. Decision to treat ABPA was uniform across regions, but the consideration of Aspergillus bronchitis as a clinical disease warranting therapy differed between regions. The use of glucocorticoid and itraconazole was the first-line treatment of ABPA among clinicians; however, prednisone monotherapy was more common in US and Canada. CONCLUSIONS Significant variability in the diagnosis and management of Aspergillus-related conditions in CF was observed. Future studies are necessary to better harmonize the approach to Af-related disease in CF.
Collapse
Affiliation(s)
- Gina Hong
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sameer Desai
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Richard B Moss
- Center of Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Patience Eschenhagen
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Bradley S Quon
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany; Centre for Heart Lung Innovation, University of British Columbia and St. Paul's Hospital; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Carsten Schwarz
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
27
|
Detailleur S, Vos R, Goeminne P. The Deteriorating Patient: Therapies Including Lung Transplantation. Semin Respir Crit Care Med 2021; 42:623-638. [PMID: 34261186 DOI: 10.1055/s-0041-1730946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In this review paper, we discuss the characteristics that define severe bronchiectasis and which may lead to deterioration of noncystic fibrosis bronchiectasis. These characteristics were used to establish the current severity scores: bronchiectasis severity index (BSI), FACED, and E-FACED (exacerbation frequency, forced expiratory volume in 1 second, age, colonization, extension and dyspnea score). They can be used to predict mortality, exacerbation rate, hospital admission, and quality of life. Furthermore, there are different treatable traits that contribute to severe bronchiectasis and clinical deterioration. When present, they can be a target of the treatment to stabilize bronchiectasis.One of the first steps in treatment management of bronchiectasis is evaluation of compliance to already prescribed therapy. Several factors can contribute to treatment adherence, but to date no real interventions have been published to ameliorate this phenomenon. In the second step, treatment in deteriorating patients with bronchiectasis should be guided by the predominant symptoms, for example, cough, sputum, difficulty expectoration, exacerbation rate, or physical impairment. In the third step, we evaluate treatable traits that could influence disease severity in the deteriorating patient. Finally, in patients who are difficult to treat despite maximum medical treatment, eligibility for surgery (when disease is localized), should be considered. In case of end-stage disease, the evaluation for lung transplantation should be performed. Noninvasive ventilation can serve as a bridge to lung transplantation in patients with respiratory failure.
Collapse
Affiliation(s)
- Stephanie Detailleur
- Department of Respiratory Diseases, University Hospital Gasthuisberg, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospital Gasthuisberg, Leuven, Belgium
| | - Pieter Goeminne
- Department of Respiratory Diseases, AZ Nikolaas, Sint-Niklaas, Belgium
| |
Collapse
|
28
|
Abstract
Introduction: Invasive fungal infection carries a high morbidity, mortality and economic cost. In recent times, a rising incidence of fungal infection and antifungal resistance is occurring which has prompted the development of novel antifungal agents.Areas covered:In this perspective, the authors describe the current status of registered antifungals and their limitations in the treatment of invasive fungal infection. They also go on to describe the new antifungal agents that are in the clinical stage of development and how they might be best utilized in patient care in the future.Expert opinion: The antifungal drug development pipeline has responded to a growing need for new agents to effectively treat fungal disease without concomitant toxicity or issues with drug tolerance. Olorofim (F901318), ibrexafungerp (SCY-078), fosmanogepix (APX001), rezafungin (CD101), oteseconazole (VT-1161), encochleated amphotericin B (MAT2203), nikkomycin Z (NikZ) and ATI-2307 are all in the clinical stage of development and offer great promise in offering clinicians better agents to treat these difficult infections.
Collapse
Affiliation(s)
- Adam G Stewart
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
| | - David L Paterson
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
| |
Collapse
|
29
|
Dhooria S, Sehgal IS, Muthu V, Agarwal R. Treatment of allergic bronchopulmonary aspergillosis: from evidence to practice. Future Microbiol 2021; 15:365-376. [PMID: 32286102 DOI: 10.2217/fmb-2019-0276] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder caused by dysregulated immune responses against Aspergillus fumigatus. The disorder usually complicates the course of patients with asthma and cystic fibrosis. Patients with ABPA most often present with asthma that is poorly controlled despite inhaled corticosteroids and long-acting β2 agonists. The treatment of ABPA is complicated due to the occurrence of recurrent exacerbations and spontaneous remissions. The drugs used for treating ABPA include systemic glucocorticoids, antifungal agents and biologics, each with its own benefits and drawbacks. In this review, we illustrate the treatment pathway for ABPA in different situations, using a case-based approach. In each case, we present the options for treatment based on the available evidence from recent clinical trials.
Collapse
Affiliation(s)
- Sahajal Dhooria
- 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
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| |
Collapse
|
30
|
Snen H, Kallel A, Blibech H, Jemel S, Salah NB, Marouen S, Mehiri N, Belhaj S, Louzir B, Kallel K. Case Report: Allergic Bronchopulmonary Aspergillosis Revealing Asthma. Front Immunol 2021; 12:695954. [PMID: 34239516 PMCID: PMC8259593 DOI: 10.3389/fimmu.2021.695954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/08/2021] [Indexed: 01/26/2023] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is an immunological pulmonary disorder caused by hypersensitivity to Aspergillus which colonizes the airways of patients with asthma and cystic fibrosis. Its diagnosis could be difficult in some cases due to atypical presentations especially when there is no medical history of asthma. Treatment of ABPA is frequently associated to side effects but cumulated drug toxicity due to different molecules is rarely reported. An accurate choice among the different available molecules and effective on ABPA is crucial. We report a case of ABPA in a woman without a known history of asthma. She presented an acute bronchitis with wheezing dyspnea leading to an acute respiratory failure. She was hospitalized in the intensive care unit. The bronchoscopy revealed a complete obstruction of the left primary bronchus by a sticky greenish material. The culture of this material isolated Aspergillus fumigatus and that of bronchial aspiration fluid isolated Pseudomonas aeruginosa. The diagnosis of ABPA was based on elevated eosinophil count, the presence of specific IgE and IgG against Aspergillus fumigatus and left segmental collapse on chest computed tomography. The patient received an inhaled treatment for her asthma and a high dose of oral corticosteroids for ABPA. Her symptoms improved but during the decrease of corticosteroids, the patient presented a relapse. She received itraconazole in addition to corticosteroids. Four months later, she presented a drug-induced hepatitis due to itraconazole which was immediately stopped. During the monitoring of her asthma which was partially controlled, the patient presented an aseptic osteonecrosis of both femoral heads that required surgery. Nine months after itraconazole discontinuation, she presented a second relapse of her ABPA. She received voriconazole for nine months associated with a low dose of systemic corticosteroid therapy with an improvement of her symptoms. After discontinuation of antifungal treatment, there was no relapse for one year follow-up.
Collapse
Affiliation(s)
- Houda Snen
- Pulmonary Department, Hospital Mongi Slim, La Marsa, Tunisia.,Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Aicha Kallel
- Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia.,Parasitology and Mycology Department, La Rabta Hospital, Tunis, Tunisia
| | - Hana Blibech
- Pulmonary Department, Hospital Mongi Slim, La Marsa, Tunisia.,Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Sana Jemel
- Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia.,Parasitology and Mycology Department, La Rabta Hospital, Tunis, Tunisia
| | - Nozha Ben Salah
- Pulmonary Department, Hospital Mongi Slim, La Marsa, Tunisia.,Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Sonia Marouen
- Parasitology and Mycology Department, La Rabta Hospital, Tunis, Tunisia
| | - Nadia Mehiri
- Pulmonary Department, Hospital Mongi Slim, La Marsa, Tunisia.,Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Slah Belhaj
- Parasitology and Mycology Department, La Rabta Hospital, Tunis, Tunisia
| | - Bechir Louzir
- Pulmonary Department, Hospital Mongi Slim, La Marsa, Tunisia.,Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Kalthoum Kallel
- Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia.,Parasitology and Mycology Department, La Rabta Hospital, Tunis, Tunisia
| |
Collapse
|
31
|
Cadena J, Thompson GR, Patterson TF. Aspergillosis: Epidemiology, Diagnosis, and Treatment. Infect Dis Clin North Am 2021; 35:415-434. [PMID: 34016284 DOI: 10.1016/j.idc.2021.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The spectrum of disease produced by Aspergillus species ranges from allergic syndromes to chronic pulmonary conditions and invasive infections. Invasive aspergillosis is a major cause of morbidity and mortality in immunocompromised patients. Risk factors continue to evolve and include newer biological agents that target the immune system and postinfluenza infection; and it has been observed following COVID-19 infection. Diagnosis remains a challenge but non-culture-based methods are available. Antifungal resistance has emerged. Voriconazole remains the treatment of choice but isavuconazole and posaconazole have similar efficacy with less toxicity. Combination therapy is used with extensive infection and in severe immunosuppression.
Collapse
Affiliation(s)
- Jose Cadena
- Department of Medicine, Division of Infectious Diseases, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive - MSC 7881, San Antonio, TX 78229-3900, USA
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California - Davis Health; Department of Medical Microbiology and Immunology, University of California - Davis Health.
| | - Thomas F Patterson
- Department of Medicine, Division of Infectious Diseases, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive - MSC 7881, San Antonio, TX 78229-3900, USA
| |
Collapse
|
32
|
Wardlaw AJ, Rick EM, Pur Ozyigit L, Scadding A, Gaillard EA, Pashley CH. New Perspectives in the Diagnosis and Management of Allergic Fungal Airway Disease. J Asthma Allergy 2021; 14:557-573. [PMID: 34079294 PMCID: PMC8164695 DOI: 10.2147/jaa.s251709] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/04/2021] [Indexed: 12/23/2022] Open
Abstract
Allergy to airway-colonising, thermotolerant, filamentous fungi represents a distinct eosinophilic endotype of often severe lung disease. This endotype, which particularly affects adult asthma, but also complicates other airway diseases and sometimes occurs de novo, has a heterogeneous presentation ranging from severe eosinophilic asthma to lobar collapse. Its hallmark is lung damage, characterised by fixed airflow obstruction (FAO), bronchiectasis and lung fibrosis. It has a number of monikers including severe asthma with fungal sensitisation (SAFS) and allergic bronchopulmonary aspergillosis/mycosis (ABPA/M), but these exclusive terms constitute only sub-sets of the condition. In order to capture the full extent of the syndrome we prefer the inclusive term allergic fungal airway disease (AFAD), the criteria for which are IgE sensitisation to relevant fungi in association with airway disease. The primary fungus involved is Aspergillus fumigatus, but a number of other thermotolerant species from several genera have been implicated. The unifying mechanism involves germination of inhaled fungal spores in the lung in the context of IgE sensitisation, leading to a persistent and vigorous eosinophilic inflammatory response in association with release of fungal proteases. Most allergenic fungi, including Alternaria and Cladosporium species, are not thermotolerant and cannot germinate in the airways so only act as aeroallergens and do not cause AFAD. Studies of the airway mycobiome have shown that A. fumigatus colonises the normal as much as the asthmatic airway, suggesting it is the tendency to become IgE-sensitised that is the critical triggering factor for AFAD rather than colonisation per se. Treatment is aimed at preventing exacerbations with glucocorticoids and increasingly by the use of anti-T2 biological therapies. Anti-fungal therapy has a limited place in management, but is an effective treatment for fungal bronchitis which complicates AFAD in about 10% of cases.
Collapse
Affiliation(s)
- Andrew J Wardlaw
- Institute for Lung Health, Department of Respiratory Sciences, College of Life Sciences, University of Leicester, and Allergy and Respiratory Medicine Service, NIHR Biomedical Research Centre: Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Eva-Maria Rick
- Institute for Lung Health, Department of Respiratory Sciences, College of Life Sciences, University of Leicester, and Allergy and Respiratory Medicine Service, NIHR Biomedical Research Centre: Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Leyla Pur Ozyigit
- Allergy and Respiratory Services University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alys Scadding
- Allergy and Respiratory Services University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Erol A Gaillard
- Institute for Lung Health, Department of Respiratory Sciences, College of Life Sciences, Department of Paediatrics, NIHR Biomedical Research Centre: Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Catherine H Pashley
- Institute for Lung Health, Department of Respiratory Sciences, College of Life Sciences, University of Leicester, and Allergy and Respiratory Medicine Service, NIHR Biomedical Research Centre: Respiratory, University Hospitals of Leicester NHS Trust, Leicester, UK
| |
Collapse
|
33
|
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.].
Collapse
|
34
|
Curran AK, Hava DL. Allergic Diseases Caused by Aspergillus Species in Patients with Cystic Fibrosis. Antibiotics (Basel) 2021; 10:antibiotics10040357. [PMID: 33800658 PMCID: PMC8067098 DOI: 10.3390/antibiotics10040357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/12/2021] [Accepted: 03/24/2021] [Indexed: 01/04/2023] Open
Abstract
Aspergillus spp. are spore forming molds; a subset of which are clinically relevant to humans and can cause significant morbidity and mortality. A. fumigatus causes chronic infection in patients with chronic lung disease such as asthma, chronic obstructive pulmonary disease (COPD) and cystic fibrosis (CF). In patients with CF, A. fumigatus infection can lead to allergic disease, such as allergic bronchopulmonary aspergillosis (ABPA) which is associated with high rates of hospitalizations for acute exacerbations and lower lung function. ABPA results from TH2 immune response to Aspergillus antigens produced during hyphal growth, marked by high levels of IgE and eosinophil activation. Clinically, patients with ABPA experience difficulty breathing; exacerbations of disease and are at high risk for bronchiectasis and lung fibrosis. Oral corticosteroids are used to manage aspects of the inflammatory response and antifungal agents are used to reduce fungal burden and lower the exposure to fungal antigens. As the appreciation for the severity of fungal infections has grown, new therapies have emerged that aim to improve treatment and outcomes for patients with CF.
Collapse
Affiliation(s)
| | - David L. Hava
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
- Correspondence:
| |
Collapse
|
35
|
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: 52] [Impact Index Per Article: 17.3] [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.
Collapse
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
| |
Collapse
|
36
|
Yanagihara T, Hirota M, Egashira A, Harada Y, Ogo N, Asoh T, Kuramoto T, Matsui G, Maeyama T. Successful treatment with mepolizumab for allergic bronchopulmonary mycosis complicated with bilateral septic arthritis of the knee joints caused by Methicillin-resistant Staphylococcus aureus. Respir Med Case Rep 2020; 31:101316. [PMID: 33318922 PMCID: PMC7723802 DOI: 10.1016/j.rmcr.2020.101316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/27/2020] [Accepted: 12/02/2020] [Indexed: 12/17/2022] Open
Abstract
We report the case of a 50-year-old man with allergic bronchopulmonary mycosis (ABPM) complicated with bilateral septic arthritis of the knees caused by Methicillin-resistant Staphylococcus aureus (MRSA). He had a background of bronchial asthma and end-stage renal failure on maintenance dialysis. He was treated with 30 mg/day of prednisolone for 14 days for ABPM. He developed bilateral septic arthritis of the knees, caused by MRSA during prednisolone treatment. He underwent bilateral arthroscopic washout with a 2-week course of intra-articular arbekacin, concomitantly treated with a 6-week course of intravenous teicoplanin and oral rifampicin, subsequently followed by oral linezolid treatment. However, he suffered exacerbation of ABPM during treatment of septic arthritis. Because of these serious infectious complications, he was treated with mepolizumab instead of corticosteroids for the ABPM, which resolved all symptoms and clinical features. This case highlights mepolizumab treatment as an alternative to corticosteroid therapy for treatment of ABPM in patients with comorbidities such as infection.
Collapse
Affiliation(s)
- Toyoshi Yanagihara
- Department of Respiratory Medicine, Hamanomachi Hospital, Fukuoka, 810-8539, Japan
- Corresponding author.
| | - Mao Hirota
- Department of Respiratory Medicine, Hamanomachi Hospital, Fukuoka, 810-8539, Japan
| | - Ayaka Egashira
- Department of Respiratory Medicine, Hamanomachi Hospital, Fukuoka, 810-8539, Japan
| | - Yukiko Harada
- Department of Clinical Infectious Diseases, Hamanomachi Hospital, Fukuoka, 810-8539, Japan
| | - Naruhiko Ogo
- Department of Respiratory Medicine, Hamanomachi Hospital, Fukuoka, 810-8539, Japan
| | - Tatsuma Asoh
- Department of Respiratory Medicine, Hamanomachi Hospital, Fukuoka, 810-8539, Japan
| | - Takahumi Kuramoto
- Department of Orthopedics, Hamanomachi Hospital, Fukuoka, 810-8539, Japan
| | - Gen Matsui
- Department of Orthopedics, Hamanomachi Hospital, Fukuoka, 810-8539, Japan
| | - Takashige Maeyama
- Department of Respiratory Medicine, Hamanomachi Hospital, Fukuoka, 810-8539, Japan
| |
Collapse
|
37
|
Rapeport WG, Ito K, Denning DW. The role of antifungals in the management of patients with severe asthma. Clin Transl Allergy 2020; 10:46. [PMID: 33292524 PMCID: PMC7646070 DOI: 10.1186/s13601-020-00353-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/19/2020] [Indexed: 12/26/2022] Open
Abstract
In patients with asthma, the inhalation of elevated amounts of fungal spores and hyphae may precipitate the onset of asthma or worsen control to the extent of being life-threatening. Sensitisation to fungi, especially Aspergillus fumigatus, is found in 15% to 48% of asthmatics in secondary care and is linked to worse asthma control, hospitalisation, bronchiectasis and fixed airflow obstruction, irrespective of whether allergic bronchopulmonary aspergillosis (ABPA) is diagnosed. ABPA represents a florid response to the presence of Aspergillus spp. but up to 70% of patients with severe asthma exhibit sensitisation to different fungi without meeting the diagnostic criteria for ABPA. The presence of persistent endobronchial colonisation with fungi, especially A. fumigatus, is linked to significantly higher rates of radiological abnormalities, lower post-bronchodilator FEV1 and significantly less reversibility to short acting bronchodilators. The therapeutic benefit for antifungal intervention in severe asthma is based on the assumption that reductions in airway fungal burden may result in improvements in asthma control, lung function and symptoms (especially cough). This contention is supported by several prospective studies which demonstrate the effectiveness of antifungals for the treatment of ABPA. Significantly, these studies confirm lower toxicity of treatment with azoles versus high dose oral corticosteroid dosing regimens for ABPA. Here we review recent evidence for the role of fungi in the progression of severe asthma and provide recommendations for the use of antifungal agents in patients with severe asthma, airways fungal infection (mycosis) and fungal colonisation. Documenting fungal airways colonisation and sensitisation in those with severe asthma opens up alternative therapy options of antifungal therapy, which may be particularly valuable in low resource settings.
Collapse
Affiliation(s)
- W Garth Rapeport
- Airways Disease, National Heart and Lung Institute, Imperial College, London, SW3 6LY, UK.
| | - Kazuhiro Ito
- Airways Disease, National Heart and Lung Institute, Imperial College, London, SW3 6LY, UK
- Pulmocide Ltd., 44 Southampton Building, London, WC2A 1AP, UK
| | - David W Denning
- Manchester Fungal Infection Group (MFIG), Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| |
Collapse
|
38
|
Barry J, Gadre A, Akuthota P. Hypersensitivity pneumonitis, allergic bronchopulmonary aspergillosis and other eosinophilic lung diseases. Curr Opin Immunol 2020; 66:129-135. [PMID: 33166785 DOI: 10.1016/j.coi.2020.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022]
Abstract
Hypersensitivity pneumonitis (HP) is traditionally classified into acute, subacute and chronic forms. A high index of suspicion and a detailed investigation into the patient's environment is the key to diagnosis and treatment of HP. Eosinophilic lung diseases can be broadly categorized as idiopathic (acute eosinophilic pneumonia, chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndromes), those with known cause (allergic bronchopulmonary aspergillosis, drugs, parasitic and non-parasitic infections), and those associated with other known lung diseases (asthma, interstitial lung diseases and lung cancers). A detailed review of drug intake, toxin exposures, and travel history is essential in the differential diagnosis of eosinophilic lung diseases.
Collapse
Affiliation(s)
- Jeffrey Barry
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States
| | - Abhishek Gadre
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States
| | - Praveen Akuthota
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States.
| |
Collapse
|
39
|
Kono Y, To M, Tsuzuki R, Yamawaki S, Soeda S, To Y. Pulmonary emphysema is associated with fungal sensitization in asthma. J Thorac Dis 2020; 12:5879-5886. [PMID: 33209420 PMCID: PMC7656412 DOI: 10.21037/jtd-20-995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Fungal sensitization is a risk factor for severe asthma. Colonization in the lower respiratory tract is one of the forms of fungal exposure, and it is related to fungal sensitization. Pulmonary emphysema was recently reported to be an underlying disease of fungal colonization. The aim of study was to evaluate the prevalence of pulmonary emphysema in asthmatic patients with and without fungal sensitization. Methods We enrolled 108 patients with allergic asthma and divided them into the patients sensitized to Aspergillus and/or Candida (n=56) and those not sensitized to both Aspergillus and Candida (n=52). The presence of pulmonary emphysema on chest CT was evaluated retrospectively. Results The frequency of pulmonary emphysema was significantly higher in the patients sensitized to Aspergillus and/or Candida compared to the patients not sensitized to both fungi (P=0.0040). The frequency of pulmonary emphysema was also significantly higher in the patients sensitized to either Aspergillus or Candida compared to the patient not sensitized to the fungi (P=0.0398 and P=0.0198, respectively). A multivariate logistic regression analysis demonstrated that the presence of pulmonary emphysema was independently associated with the sensitization to Aspergillus and/or Candida (OR 7.84, 95% CI: 1.20–51.10). Conclusions Pulmonary emphysema is associated with sensitization to Aspergillus and/or Candida.
Collapse
Affiliation(s)
- Yuta Kono
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Masako To
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Ryuta Tsuzuki
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Satoshi Yamawaki
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Seiko Soeda
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Yasuo To
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Tokyo, Japan
| |
Collapse
|
40
|
Rosenberg CE, Khoury P. Approach to Eosinophilia Presenting With Pulmonary Symptoms. Chest 2020; 159:507-516. [PMID: 33002503 DOI: 10.1016/j.chest.2020.09.247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/14/2020] [Accepted: 09/18/2020] [Indexed: 12/17/2022] Open
Abstract
Eosinophilia with pulmonary involvement is characterized by the presence of peripheral blood eosinophilia, typically ≥500 cells/mm3, by pulmonary symptoms and physical examination findings that are nonspecific, and by radiographic evidence of pulmonary disease and is further supported by histopathologic evidence of tissue eosinophilia in a lung or pleura biopsy specimen and/or increased eosinophils in BAL fluid, usually >10%. Considering that there are a variety of underlying causes of eosinophilia with pulmonary manifestations and overlapping clinical, laboratory, and radiologic features, it is essential to approach the evaluation of eosinophilia with pulmonary findings systematically. In this review, we will describe a case presentation and discuss the differential diagnosis, a directed approach to the diagnostic evaluation and supporting literature, the current treatment strategies for pulmonary eosinophilia syndromes, and the levels of evidence underlying the recommendations, where available. Overall, optimal management of eosinophilic lung disease presentations are directed at the underlying cause when identifiable, and the urgency of treatment may be guided by the presence of severe end-organ involvement or life-threatening complications. When an underlying cause is not easily attributable, management of eosinophilia with pulmonary involvement largely relies on eosinophil-directed interventions, for which biologic therapies are increasingly being used.
Collapse
Affiliation(s)
- Chen E Rosenberg
- Department of Pediatrics, Division of Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Paneez Khoury
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.
| |
Collapse
|
41
|
Russo A, Tiseo G, Falcone M, Menichetti F. Pulmonary Aspergillosis: An Evolving Challenge for Diagnosis and Treatment. Infect Dis Ther 2020; 9:511-524. [PMID: 32638227 PMCID: PMC7339098 DOI: 10.1007/s40121-020-00315-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Indexed: 02/07/2023] Open
Abstract
Aspergillus is a mold that may lead to different clinical pictures, from allergic to invasive disease, depending on the patient’s immune status and structural lung diseases. Chronic pulmonary aspergillosis is an infection with a locally invasive presentation, reported especially in patients with chronic pulmonary disease, while aspergilloma is typically found in patients with previously formed cavities in the lungs. Allergic bronchopulmonary aspergillosis is due to a hypersensitivity reaction to Aspergillus antigens and is more frequently described in patients with moderate-severe asthma or cystic fibrosis. Invasive pulmonary aspergillosis mainly occurs in patients with neutropenia or immunodeficiency, but has increasingly been recognized as an emerging disease of non-neutropenic patients. The significance of this infection has dramatically increased in recent years, considering the high number of patients with an impaired immune state associated with the management and treatment of neoplasm, solid or hematological transplantation, autoimmune diseases, and inflammatory conditions. Moreover, prolonged steroid treatment is recognized as an important risk factor, especially for invasive disease. In this setting, critically ill patients admitted to intensive care units and/or with chronic obstructive pulmonary disease could be at higher risk for invasive infection. This review provides an update on the clinical features and risk factors of pulmonary aspergillosis. Current approaches for the diagnosis, management, and treatment of these different forms of pulmonary aspergillosis are discussed.
Collapse
Affiliation(s)
- Alessandro Russo
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Giusy Tiseo
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marco Falcone
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesco Menichetti
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| |
Collapse
|
42
|
Pulmonary Aspergillosis: What the Generalist Needs to Know. Am J Med 2020; 133:668-674. [PMID: 32240631 DOI: 10.1016/j.amjmed.2020.02.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022]
Abstract
Aspergillus spp. is a ubiquitous mold found commonly in our environment that can cause a spectrum of pulmonary disorders, ranging from a hypersensitivity reaction to an acutely invasive disease with significant mortality. Allergic bronchopulmonary aspergillosis results from airway hypersensitivity from aspergillus colonization almost exclusively in patients with asthma and cystic fibrosis. Chronic pulmonary aspergillosis typically presents in immunocompetent patients with underlying lung pathology. Treatment is primarily with antifungal agents; however, other measures such as surgical resection may be necessary. Invasive pulmonary aspergillosis is a severe infection in immunocompromised patients and is characterized by invasion of pulmonary vasculature by the Aspergillus hyphae. Recent advances in the diagnosis and management of invasive pulmonary aspergillosis include emerging risk factors such as critically ill patients, and those with chronic obstructive pulmonary disease and liver disease. In addition, noninvasive biomarkers have made it easier to suspect and diagnose invasive pulmonary aspergillosis. There are more effective and better-tolerated antifungal agents that have improved patient outcomes. This review introduces the spectrum of pulmonary aspergillosis geared toward generalists, including disease manifestations, most recent diagnostic criteria, and first-line treatment options. Involving a multidisciplinary team is vital to the early diagnosis and management of these diseases.
Collapse
|
43
|
Schleich F, Vaia ES, Pilette C, Vandenplas O, Halloy JL, Michils A, Peche R, Hanon S, Louis R, Michel O. Mepolizumab for allergic bronchopulmonary aspergillosis: Report of 20 cases from the Belgian Severe Asthma Registry and review of the literature. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2412-2413.e2. [PMID: 32268213 DOI: 10.1016/j.jaip.2020.03.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/31/2020] [Accepted: 03/11/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Florence Schleich
- Department of Respiratory Medicine, CHU Sart-Tilman Liege, University of Liege, Liege, Belgium.
| | | | - Charles Pilette
- Laboratory of Allergy & Mucosal Immunology and Cliniques Universitaires St-Luc, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Olivier Vandenplas
- Department of Respiratory Medicine, CHU of Mont-Godinne, Université Catholique de Louvain, Yvoir, Belgium
| | - Jean-Luc Halloy
- Department of Respiratory Medicine, centre hospitalier EpiCURA, Site de Baudour, Belgium
| | - Alain Michils
- Chest Department, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Rudy Peche
- Department of Respiratory Medicine, CHU-Charleroi, A.Vésale Hospital, Charleroi, Belgium
| | - Shane Hanon
- Department of Respiratory Medicine, Universitair Ziekenhuis, Brussels, Belgium
| | - Renaud Louis
- Department of Respiratory Medicine, CHU Sart-Tilman Liege, University of Liege, Liege, Belgium
| | - Olivier Michel
- Clinical Immunoallergology, CHU Brugmann, ULB, Brussels, Belgium
| |
Collapse
|
44
|
Fukushima C, Matsuse H, Obase Y, Fukahori S, Tsuchida T, Kawano T, Kohno S, Mukae H. Liposomal Amphotericin B Fosters the Corticosteroids' Anti-inflammatory Effect on Murine Allergic Bronchopulmonary Aspergillosis Model Airways. Inflammation 2020; 42:2065-2071. [PMID: 31396817 DOI: 10.1007/s10753-019-01069-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Fungus is an antigen for bronchial asthma causing allergic bronchopulmonary mycosis (ABPM). As a therapy other than corticosteroids, itraconazole (ITCZ) is known to suppress the allergic inflammation induced by Aspergillus fumigatus (Af). However, the efficacy of liposomal amphotericin B (LAMB) with/without corticosteroid on ABPM is unknown. Mice sensitized to Dermatophagoides farinae (Df) allergen were intranasally infected with Af (DfAf group). After the infection, corticosteroid (dexamethasone (Dex)) was administered for 5 days (DfAf/Dex group). The effects of ITCZ or LAMB with/without Dex were also evaluated. Pathologically, Dex and LAMB combination treatment decreased the allergic inflammation evidently. The bronchoalveolar lavage fluid (BALF) concentrations of IL-5, IL-13, and MIP-2 were significantly elevated in DfAf mice compared with control mice (p < 0.05, each). In DfAf mice, ITCZ and LAMB significantly decreased the elevation of MIP-2 (p < 0.05 vs the DfAf group). The addition of both Dex and LAMB suppressed the MIP-2 elevation in DfAf mice (p < 0.05 vs the Df/Af/Dex/LAMB group), but the addition of Dex and ITCZ did not (DfAf/Dex/ITCZ group). None of Dex, ITCZ, or LAMB decreased pulmonary IL-13 concentration. It was suggested that combination of antifungal drugs and corticosteroid enhanced the suppressing effect of airway inflammations. This finding will give a hope for the treatment of severe fungus-related asthma.
Collapse
Affiliation(s)
- Chizu Fukushima
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroto Matsuse
- Division of Respiratory Medicine, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Susumu Fukahori
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tomoko Tsuchida
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuya Kawano
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shigeru Kohno
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| |
Collapse
|
45
|
Treating Allergic Bronchopulmonary Aspergillosis with Short-Term Prednisone and Itraconazole in Cystic Fibrosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2608-2614.e3. [PMID: 32147521 DOI: 10.1016/j.jaip.2020.02.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/21/2020] [Accepted: 02/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus fumigatus contributing to cystic fibrosis (CF) lung disease. OBJECTIVE To evaluate the combination of oral prednisone for 18 days together with itraconazole therapy for at least 12 months in CF-related ABPA with regard to long-term pulmonary function and side effects. METHODS Sixty-five patients with CF treated for ABPA and 127 patients with CF without ABPA serving as matched controls were retrospectively analyzed for a median period of 4.8 years. Serial lung functions were analyzed alongside clinical, microbiological, and laboratory data including itraconazole therapeutic drug monitoring. RESULTS The used ABPA treatment regimen restored FEV1 values to pre-ABPA levels within 3 months (P < .0001). Long-term FEV1 courses of patients showed no difference when compared with those of ABPA-free controls. Glucocorticoid treatment was not associated with increased CF-related diabetes incidence, growth restriction, or Pseudomonas aeruginosa acquisition. Patients who experienced ABPA relapses displayed lower itraconazole trough levels during the first 3 months of treatment (P < .05). A decreased risk of ABPA recurrence was further associated with P aeruginosa colonization. CONCLUSIONS The proposed treatment scheme for CF-related ABPA is effective in preserving lung function capacity over years in affected individuals without the known glucocorticoid-associated side effects. Itraconazole therapeutic drug monitoring seems useful to prevent disease flares, for which P aeruginosa-negative patients with CF might be particularly susceptible.
Collapse
|
46
|
Otu AA, Langridge P, Denning DW. An evaluation of nebulised amphotericin B deoxycholate (Fungizone ® ) for treatment of pulmonary aspergillosis in the UK National Aspergillosis Centre. Mycoses 2020; 62:1049-1055. [PMID: 31479538 DOI: 10.1111/myc.12996] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/21/2019] [Accepted: 08/27/2019] [Indexed: 12/12/2022]
Abstract
Antifungal treatment options for allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS) are largely limited to itraconazole based on the outcome of randomised controlled trials. It is unclear if nebulised amphotericin B deoxycholate (Fungizone® ) is a viable therapeutic option. We evaluated the safety and efficacy of nebulised Fungizone® in the long-term treatment of various forms of pulmonary aspergillosis. We assessed the records of 177 patients with various forms of pulmonary aspergillosis attending the National Aspergillosis Centre in Manchester who had received Fungizone® . Patients first received a challenge test with nebulised Fungizone® in hospital with spirometry pre/post-Fungizone® and nebulised salbutamol given pre-Fungizone® . Tolerability and changes in Aspergillus IgE, Aspergillus IgG and total IgE were evaluated. Sixty-six per cent (117/177) were able to tolerate the test dose of Fungizone® and in all cases, the reason for discontinuation of the first test dose was worsening breathlessness. Twenty six (21%) stopped therapy within 4-6 weeks, and the commonest reason cited for discontinuation of therapy was increased breathlessness, hoarseness and cough. Eighteen (10.2%) patients continued the Fungizone® for >3 months of which 5 (27.8%) recorded an improvement in total IgE, Aspergillus-specific IgE and Aspergillus IgG. Eleven had ABPA, four had SAFS, two had Aspergillus bronchitis and one had Aspergillus sensitisation with cavitating nodules. Among these 18 patients, sputum fungal culture results went from positive to negative in five patients, became positive in one patient, remained positive in three patients, and remained negative in seven patients. Nebulised Fungizone® appears to be a poorly tolerated treatment for pulmonary Aspergillosis with high dropout rates. There appears to be both clinical and serological benefits following sustained treatment with nebulised Fungizone® in some patients.
Collapse
Affiliation(s)
- Akaninyene A Otu
- The National Aspergillosis Centre, 2nd Floor Education and Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,College of Medical Sciences, University of Calabar, Calabar, Nigeria
| | - Philip Langridge
- The National Aspergillosis Centre, 2nd Floor Education and Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - David W Denning
- The National Aspergillosis Centre, 2nd Floor Education and Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Manchester, UK
| |
Collapse
|
47
|
Hava DL, Tan L, Johnson P, Curran AK, Perry J, Kramer S, Kane K, Bedwell P, Layton G, Swann C, Henderson D, Khan N, Connor L, McKenzie L, Singh D, Roach J. A phase 1/1b study of PUR1900, an inhaled formulation of itraconazole, in healthy volunteers and asthmatics to study safety, tolerability and pharmacokinetics. Br J Clin Pharmacol 2020; 86:723-733. [PMID: 31696544 DOI: 10.1111/bcp.14166] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 09/30/2019] [Accepted: 10/17/2019] [Indexed: 01/21/2023] Open
Abstract
AIMS Oral itraconazole has variable pharmacokinetics and risks of adverse events associated with high plasma exposure. An inhalation formulation of itraconazole (PUR1900) is being developed to treat allergic bronchopulmonary aspergillosis, an allergic inflammatory disease occurring in asthmatics and patients with cystic fibrosis. METHODS A 3-part, open-label Phase 1 study was conducted to evaluate safety, tolerability and pharmacokinetics of PUR1900. Healthy volunteers (n = 5-6/cohort) received either single (Part 1) or multiple (Part 2) ascending doses of PUR1900 for up to 14 days. In Part 3 stable, adult asthmatics received a single dose of 20 mg PUR1900 or 200 mg of oral Sporanox (itraconazole oral solution) in a 2-period randomized cross-over design. Itraconazole plasma and sputum concentrations were evaluated. RESULTS None of the adverse events considered as at least possibly related to study treatment were moderate or severe, and none were classed as serious. The most common was the infrequent occurrence of mild cough. Itraconazole plasma exposure increased with increasing doses of PUR1900. After 14 days, PUR1900 resulted in plasma exposure (area under the concentration-time curve up to 24 h) 106- to 400-fold lower across doses tested (10-35 mg) than steady-state exposure reported for oral Sporanox 200 mg. In asthmatics, PUR1900 geometric mean maximum sputum concentrations were 70-fold higher and geometric mean plasma concentrations were 66-fold lower than with oral Sporanox. CONCLUSION PUR1900 was safe and well-tolerated under the study conditions. Compared to oral dosing, PUR1900 achieved higher lung and lower plasma exposure. The pharmacokinetic profile of PUR1900 suggests the potential to improve upon the efficacy and safety profile observed with oral itraconazole.
Collapse
Affiliation(s)
| | - Lisa Tan
- Lisa Tan Pharma Consulting, Kingston, Cambridge, UK
| | | | | | | | | | | | | | | | | | | | - Naimat Khan
- Medicines Evaluation Unit, The Langley Building, Wythenshawe Hospital, Wythenshawe, UK, England
| | - Lucy Connor
- Medicines Evaluation Unit, The Langley Building, Wythenshawe Hospital, Wythenshawe, UK, England
| | | | - Dave Singh
- Medicines Evaluation Unit, The Langley Building, Wythenshawe Hospital, Wythenshawe, UK, England.,University of Manchester, Manchester University NHS Hospital Trust, Manchester, UK
| | | |
Collapse
|
48
|
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.
Collapse
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
| |
Collapse
|
49
|
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]
|
50
|
Mirsadraee M, Dehghan S, Ghaffari S, Mirsadraee N. Long-term effect of antifungal therapy for the treatment of severe resistant asthma: an active comparator clinical trial. Curr Med Mycol 2019; 5:1-7. [PMID: 32104737 PMCID: PMC7034786 DOI: 10.18502/cmm.5.4.1986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose: Itraconazole therapy has been reported to control asthma in severe therapy-resistant asthma with fungal sensitization. The aim of this study was to investigate the impact of anti-fungal therapy on the treatment of severe asthma, irrespective of sensitization. Materials and Methods: This active comparator clinical trial was performed on 110 therapy-resistant asthmatic patients who were randomly assigned into two groups of case and control. The patients in the case group were administered 200 mg itraconazole twice a day and the control group received 10 mg prednisolone after breakfast for 4 months. The asthma control test (ACT) which was used as a marker for the global evaluation of treatment effectiveness (GETE) was applied as the primary endpoint parameter. Cough, dyspnea, and sleep disturbance were measured on a scale of 1-4, with 1 representing no symptom and 4 indicating severe exhausting disturbance. Results: Based on the obtained results, 71% of the itraconazole group demonstrated a marked improvement in the GETE score after a four-month treatment. Itraconazole was able to suppress clinical symptoms, including cough, dyspnea, and night symptoms, and their physical exam was indicative of normalization in 60% of the patients. On the other hand, the patients in the parallel group "prednisolone" were only able to control dyspnea. The ACT score represented a notable improvement with itraconazole (mean: 14 before the trial and >20 after the trial) and spirometry parameters underwent a considerable change from obstructive pattern to normal. Furthermore, adverse effects were only detected in 6% of itraconazole users. Conclusion: The results of this clinical trial indicted the effectiveness of antifungal therapy for the control of the clinical condition of a subgroup of patients with severe steroid-refractory asthma.
Collapse
Affiliation(s)
- Majid Mirsadraee
- Internist and Pulmonologist, Professor, Islamic Azad University, Mashhad Branch, Mashhad, Iran
| | - Sanaz Dehghan
- Innovative Research Center, Faculty of Medicine, Islamic Azad University, Mashhad Branch, Mashhad, Iran
| | - Shadi Ghaffari
- MSc in Biology, Research Department, Kavosh High School, Mashhad, Iran
| | - Niloofar Mirsadraee
- MSc in Cell and Molecular Biology, Innovative Research Center, Faculty of Medicine, Islamic Azad University, Mashhad Branch, Mashhad, Iran
| |
Collapse
|