Bronchopulmonary helminthosporiosis

Allergic bronchopulmonary mycosis due to fungi other than Aspergillus: a global overview

Allergic bronchopulmonary mycosis (ABPM) is a hypersensitivity-mediated disease of worldwide distribution. We reviewed 143 reported global cases of ABPM due to fungi other than aspergilli. The commonest etiologic agent was Candida albicans, reported in 60% of the cases, followed by Bipolaris species (13%), Schizophyllum commune (11%), Curvularia species (8%), Pseudallescheria boydii species complex (3%) and rarely, Alternaria alternata, Fusarium vasinfectum, Penicillium species, Cladosporium cladosporioides, Stemphylium languinosum, Rhizopus oryzae, C. glabrata, Saccharomyces cerevisiae and Trichosporon beigelii. India accounted for about 47% of the globally reported cases of ABPM, attributed predominantly to C. albicans, followed by Japan (16%) where S. commune predominates, and the remaining one-third from the USA, Australia and Europe. Notably, bronchial asthma was present in only 32% of ABPM cases whereas its association with development of allergic bronchopulmonary aspergillosis (ABPA) is known to be much more frequent. The cases reviewed herein revealed a median IgE value threefold higher than that of ABPA, suggesting that the etiologic agents of ABPM incite a stronger immunological response than that by aspergilli in ABPA. ABPM is currently underdiagnosed, warranting comprehensive basic and clinical studies in order to elucidate its epidemiology and to devise a more effective therapy.

Induction of mucin and MUC5AC expression by the protease activity of Aspergillus fumigatus in airway epithelial cells

Allergic bronchopulmonary mycosis, characterized by excessive mucus secretion, airflow limitation, bronchiectasis, and peripheral blood eosinophilia, is predominantly caused by a fungal pathogen, Aspergillus fumigatus. Using DNA microarray analysis of NCI-H292 cells, a human bronchial epithelial cell line, stimulated with fungal extracts from A. fumigatus, Alternaria alternata, or Penicillium notatum, we identified a mucin-related MUC5AC as one of the genes, the expression of which was selectively induced by A. fumigatus. Quantitative RT-PCR, ELISA, and histochemical analyses confirmed an induction of mucin and MUC5AC expression by A. fumigatus extracts or the culture supernatant of live microorganisms in NCI-H292 cells and primary cultures of airway epithelial cells. The expression of MUC5AC induced by A. fumigatus extracts diminished in the presence of neutralizing Abs or of inhibitors of the epidermal growth factor receptor or its ligand, TGF-α. We also found that A. fumigatus extracts activated the TNF-α-converting enzyme (TACE), critical for the cleavage of membrane-bound pro-TGF-α, and its inhibition with low-molecular weight inhibitors or small interfering RNA suppressed the expression of MUC5AC. The protease activity of A. fumigatus extracts was greater than that of other fungal extracts, and treatment with a serine protease inhibitor, but not with a cysteine protease inhibitor, eliminated its ability to activate TACE or induce the expression of MUC5AC mRNA in NCI-H292. In conclusion, the prominent serine protease activity of A. fumigatus, which caused the overproduction of mucus by the bronchial epithelium via the activation of the TACE/TGF-α/epidermal growth factor receptor pathway, may be a pathogenetic mechanism of allergic bronchopulmonary mycosis.

Bipolaris hawaiiensis as etiologic agent of allergic bronchopulmonary mycosis: first case in a paediatric patient

Allergic bronchopulmonary mycosis (ABPM) is a worldwide hypersensitivity lung disease of multiple etiologies with Aspergillus fumigatus as the most common etiologic agent. We report the first instance of Bipolaris hawaiiensis causing ABPM in a paediatric patient. A six-year-old girl presented in June 2009 with productive cough, exertional dyspnoea, occasional wheezing, restricted air entry in left infra-scapular and infra-axillary areas, 7% eosinophils (absolute count 540/mm(3)) and total IgE 1051.3 IU/m in the sera. Bronchoscopy revealed narrowing of left main bronchus and mucoid impaction of the left lower lobe segmental bronchi. Cytological examination of BAL revealed few eosinophils, Charcot-Leyden crystals and mucus embedded hyphae. Examination of KOH wet mounts of repeated sputum and BAL specimens revealed septate, brownish hyphae and culture of the specimens resulted in the isolation of multiple colonies of a fungus later identified as B. hawaiiensis based on phenotypic characters and sequencing of internal transcribed spacer and D1/D2 regions of rDNA. In addition, (1-3)-β-D-glucan was demonstrated in serum (316 pg/ml) by Fungitell kit, supportive of fungal infection/colonization. Histopathologic studies of a bronchial biopsy revealed necrotic debris, macrophage aggregates, lymphocytes, polymorphs and PAS positive hypae. The patient was administered oral itraconazole for 12 weeks, intravenous liposomal amphotericin B for one month, weekly bronchoscopic suctioning and voriconazole instillation, resulting in reduced mucopurulent secretions and considerable clinical improvement. A serum sample collected on 5 November demonstrated precipitins against antigens of the B. hawaiiensis isolate. In March 2010, intradermal skin testing revealed a strong, type I hypersensitivity (induration diam-12 mm) against B. hawaiiensis. The patient relapsed with wheezing and difficulty in respiration in April 2010. Considering the positive type I cutaneous hypersensitivity, the aforementioned laboratory and clinical observations, the patient was finally diagnosed as having ABPM and was successfully treated with oral prednisone. A high index of clinical suspicion with requisite investigations is crucial for early diagnosis and appropriate therapy of ABPM in order to prevent the late sequelae of irreversible broncho-pulmonary damage.

Severe asthma and fungi: current evidence

Bronchial asthma is an inflammatory disease of the airways which may be worsened due to numerous extrinsic factors. The most common trigger is continuous exposure to allergens of which fungal agents are important factors. There is overwhelming evidence for the presence of fungal sensitization in patients with asthma. The diagnosis of fungal sensitization can be made either with skin testing with antigens derived from fungi or measuring specific IgE levels. There is also a strong association between fungal sensitization and severity of asthma. Whether this relationship is causal or just casual remains to be investigated. A variety of fungi are known to cause sensitization in asthmatics, but the most important fungal agent(s) causing severe asthma with fungal sensitization (SAFS) are currently unknown. Aspergillus species seem to be the strongest candidates as only with Aspergillus spp. does one encounter two extreme immunologic phenomena, i.e., the Aspergillus-sensitive asthma and allergic bronchopulmonary aspergillosis. The initial clinical management of SAFS should be the same as asthmatics without fungal sensitization. There is some evidence of the role of itraconazole in the management of SAFS but its routine use in SAFS requires further evaluation. This review summarizes the current evidence on the link between fungi and severe asthma.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is an immunologic pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus. Clinically, a patient presents with chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis. The population prevalence of ABPA is not clearly known, but the prevalence in asthma clinics is reported to be around 13%. The disorder needs to be detected before bronchiectasis has developed because the occurrence of bronchiectasis is associated with poorer outcomes. Because many patients with ABPA may be minimally symptomatic or asymptomatic, a high index of suspicion for ABPA should be maintained while managing any patient with bronchial asthma whatever the severity or the level of control. This underscores the need for routine screening of all patients with asthma with an Aspergillus skin test. Finally, there is a need to update and revise the criteria for the diagnosis of ABPA. This review summarizes the advances in the diagnosis and management of ABPA using a systematic search methodology.

Allergic bronchopulmonary disease caused by Bipolaris hawaiiensis presenting as a necrotizing pneumonia: case report and review of literature

We report a case of allergic bronchopulmonary disease caused by Bipolaris hawaiisensis in an immunocompetent host, presenting with symptoms and radiographic findings suggestive of necrotizing pneumonia. Cultures of the plugs and bronchial washing yielded the pathogenic fungi. Laboratory tests revealed eosinophilia and elevation of serum IgE. This patient was successfully treated with steroids, amphotericin B lipid complex, and itraconazole. Review of 10 previously reported cases and their clinical manifestations and treatment are presented.

Allergic bronchopulmonary mycosis caused by Pseudallescheria boydii

Two cases of allergic bronchopulmonary pseudallescheriosis (ABPP) are described. These are the first cases of this allergic bronchopulmonary mycosis (ABPM) reported in which the clinical and serologic criteria are described. The first case was in a patient with mild asthma, and it resolved spontaneously after expectoration of a mucous plug. The second was in a patient with recurrent allergic bronchopulmonary aspergillosis with an exacerbation of ABPM caused by Pseudallescheria boydii. The total serum IgE, IgG, and IgE antibodies against P. boydii and the clinical picture well define ABPP. This diagnosis may be important to recognize in order to prevent a progression of the patient's lung disease.

Unusual aspects of allergic bronchopulmonary fungal disease: report of two cases due to Curvularia organisms associated with allergic fungal sinusitis

We report two cases of allergic bronchopulmonary fungal disease (ABPFD) caused by Curvularia sp and associated with allergic fungal sinusitis (AFS). Curvularia lunata was cultured in one case and Curvularia senegalensis was cultured in the other. Based on these cases and a review of the literature, we discuss unusual clinical and pathologic features that can occur in ABPFD. Unusual clinical aspects of ABPFD include associated AFS, absence of asthma, progression to Churg-Strauss angiitis and granulomatosis, concomitant hypersensitivity pneumonitis, and underlying cystic fibrosis. Atypical pathologic features that may occur in ABPFD include follicular bronchiolitis, xanthomatous bronchiolitis, limited tissue invasion, fungus balls, and association with unusual fungi. Prominent follicular bronchiolitis and xanthomatous bronchiolitis were misleading histologic features in one of our cases and led to a delay in recognition of the diagnosis. Both patients presented primarily with AFS; ABPFD was detected subsequently. This suggests that a small subset of patients with AFS may be at risk for ABPFD. The goal of this review is to increase awareness of unusual clinical and pathologic manifestations of ABPFD. It is hoped that this will result in accurate diagnosis and proper therapy, especially for patients who present with atypical features. Unusual fungal species should be considered in patients who have clinical findings compatible with ABPFD but who do not demonstrate immunologic reactivity to Aspergillus sp, especially Aspergillus fumigatus. In addition, ABPFD should be considered in patients with AFS who develop new pulmonary lesions.

Allergic bronchopulmonary fungal disease caused by Bipolaris and Curvularia

Allergic bronchopulmonary fungal disease (ABPFD) usually manifests in asthmatics as allergic bronchopulmonary aspergillosis. In a few instances other fungi have been implicated. Serological testing in Western Australia between 1979 and 1986 revealed precipitins to Bipolaris and Curvularia species in 40 of 503 patients tested. Eight of these were patients with ABPFD due to Bipolaris and/or Curvularia and are reported here. Geographical location appeared to be significant as seven of eight of those with ABPFD (and at least 18 of 40 with positive serology) were living in the more remote and sub-tropical northern part of the state. ABPFD due to fungi other than Aspergillus species may be more common than previously recognised and further epidemiological assessment is warranted.

Emerging agents of phaeohyphomycosis: pathogenic species of Bipolaris and Exserohilum

Study of numerous living isolates of Bipolaris, Drechslera, Exserohilum, and Helminthosporium spp., as well as a mycological assessment of published case reports of phaeohyphomycosis attributed to these fungi, showed that Bipolaris australiensis, B. hawaiiensis, B. spicifera, Exserohilum longirostratum, E. mcginnisii, and E. rostratum are well-documented pathogens. Conidial shape, septation, and size, hilar characteristics, the origin of the germ tube from the basal cell and, to a lesser extent, from other conidial cells, and the sequence and location of the conidial septa are useful criteria for distinguishing these taxa.

An animal model of Curvularia geniculata and its relationship with human disease

The conidiospore of Curvularia geniculata was observed in the bronchial washings of a patient who subsequently developed pulmonary aspergillosis. Curvularia geniculata was grown in culture and used in experiments in mice to explore its possible role as a disease causing agent. The fungus, after intraperitoneal injection, produced granulomas in the liver and spleen. Studies on the pathogenicity of this fungus in mice produced similar lesions to those observed in the human case. A comparison of the lesions in the patient's lung and in the animal experimental model is presented.

Allergic bronchopulmonary candidiasis

A patient had an illness consistent with allergic bronchopulmonary candidiasis. She had asthma, fleeting pulmonary infiltrate, immediate skin reactivity and precipitating antibody against Candida albicans, elevated total serum IgE concentration, elevated IgE and IgG antibody activity against C albicans, and two positive sputum cultures for C albicans. Serial serologic studies showed a significant decrease of serum IgE levels and IgE antibody activity after corticosteroid treatment.

Allergic bronchopulmonary fungal disease without clinical asthma

During a retrospective survey of patients with pulmonary shadows and blood eosinophilia between the years 1965 and 1980, 42 patients were found with allergic bronchopulmonary fungal disease. Eleven of these had no clinical evidence of asthma. Three of these 11 had hypersensitivity to fungi other than Aspergillus sp. In the absence of asthma there was some difficulty in making a diagnosis, particularly where collapse of the upper lobe occurred in middle-aged or elderly patients and bronchogenic carcinoma was presumed responsible. We suggest that the term allergic bronchopulmonary aspergillosis be replaced by allergic bronchopulmonary fungal disease, the diagnosis be considered in patients with lung disease and blood eosinophilia even in the absence of asthma, and a wider range of fungal allergens be used for skin and precipitin tests.

Allergic bronchopulmonary disease caused by Curvularia lunata and Drechslera hawaiiensis

Three patients who developed bronchoceles caused by fungi other than Aspergillus sp are described. The first patient presented for investigation of a lesion at the right hilum on chest radiograph and a raised blood eosinophil count. A bronchogram showed complete block of the apical segmental bronchus which at operation was shown to be caused by inspissated material. The second patient was investigated because of a cough productive of plugs of sputum and irregular opacities in both upper zones on chest radiograph and a raised blood eosinophil count. This only cleared after one month on high dose oral prednisone therapy. The third patient with a previous history of left lingular pneumonia and bronchiectasis of the lingular segment of the left upper lobe was investigated three years later for right basal shadowing and a raised blood eosinophil count. The radiograph cleared after one month on high dose oral prednisone treatment. The aetiological agents in these cases were dematiaceous hyphomycetes, fungi ubiquitous in nature, and also agents of plant disease. The causal fungi, Curvularia lunata and Drechslera hawaiiensis, have on a few occasions been reported as causing human disease but in cases quite dissimilar to the three reported here. Septate branching dematiaceous mycelium was consistently seen in the clinical material and isolated from successive sputum specimens from each patient. Immunodiffusion tests from the third patient gave positive results for both fungi. Intraperitoneal inoculations of C lunata and D. hawaiiensis into Swiss white mice proved the pathogenicity of these isolates.

Allergic bronchopulmonary stemphyliosis

A patient is described in whom a clinical picture resembling allergic bronchopulmonary aspergillosis was found to be caused by hypersensitivity to the fungus Stemphylium lanuginosum. Bronchopulmonary reactions to antigens other than Aspergillus may be more frequent than is currently believed.