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Seo W, Kim HW, Kim JS, Min J. Long term management of people with post-tuberculosis lung disease. Korean J Intern Med 2024; 39:7-24. [PMID: 38225822 PMCID: PMC10790047 DOI: 10.3904/kjim.2023.395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/24/2023] [Accepted: 11/08/2023] [Indexed: 01/17/2024] Open
Abstract
Post-tuberculosis lung disease (PTLD) is emerging as a significant area of global interest. As the number of patients surviving tuberculosis (TB) increases, the subsequent long-term repercussions have drawn increased attention due to their profound clinical and socioeconomic impacts. A primary obstacle to its comprehensive study has been its marked heterogeneity. The disease presents a spectrum of clinical manifestations which encompass tracheobronchial stenosis, bronchiectasis, granulomas with fibrosis, cavitation with associated aspergillosis, chronic pleural diseases, and small airway diseases-all persistent consequences of PTLD. The spectrum of symptoms a patient may experience varies based on the severity of the initial infection and the efficacy of the treatment received. As a result, the long-term management of PTLD necessitates a detailed and specific approach, addressing each manifestation individually-a tailored strategy. In the immediate aftermath (0-12 months after anti-TB chemotherapy), there should be an emphasis on monitoring for relapse, tracheobronchial stenosis, and smoking cessation. Subsequent management should focus on addressing hemoptysis, managing infection including aspergillosis, and TB-associated chronic obstructive pulmonary disease or restrictive lung function. There remains a vast expanse of knowledge to be discovered in PTLD. This review emphasizes the pressing need for comprehensive, consolidated guidelines for management of patients with PTLD.
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Affiliation(s)
- Wan Seo
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Hyung Woo Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Ju Sang Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Jinsoo Min
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
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Rasheed A, McCloskey A, Foroutan S, Waheed A, Rodgers A, Seraj SM, Cason FD. Pulmonary Aspergilloma in a Young Immunocompetent Female: A Rare Clinical Dilemma. Cureus 2022; 14:e22724. [PMID: 35371658 PMCID: PMC8971099 DOI: 10.7759/cureus.22724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 01/21/2023] Open
Abstract
Depending on the host's immunological and respiratory systems, Aspergillus can induce infectious and allergic diseases. Most of the spread occurs in immunocompromised people, whereas aggressive disorder in immunocompetent patients is unusual. We report the case of a 19-year-old female who had shortness of breath, right-sided chest discomfort, and intermittent hemoptysis for six months before being diagnosed with pulmonary aspergilloma. The initial chest x-ray revealed a massive right pneumothorax and a 7.2 cm rounded opacity in the right lower lung. A subsequent computed tomography (CT) chest with contrast revealed a 6.7 cm cavitating mass occupying the right lower lobe. An open right thoracotomy and right lower lobectomy showed a cavitary fungus ball with septate branching hyphae and subsequent methenamine silver staining consistent with Aspergillus in conjunction with a positive Aspergillus antigen. We strongly suggest that pulmonary aspergillosis should be suspected regardless of age or immunocompetence in patients with prolonged cough, hemoptysis, unilateral chest discomfort, and pneumothorax.
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3
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Gupta R, Judson MA, Baughman RP. Management of Advanced Pulmonary Sarcoidosis. Am J Respir Crit Care Med 2021; 205:495-506. [PMID: 34813386 DOI: 10.1164/rccm.202106-1366ci] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The term "advanced sarcoidosis" is used for forms of sarcoidosis with a significant risk of loss of organ function or death. Advanced sarcoidosis often involves the lung and is described as "Advanced Pulmonary Sarcoidosis" (APS) which includes advanced pulmonary fibrosis, associated complications such as bronchiectasis and infections, and pulmonary hypertension. While APS affects a small proportion of patients with sarcoidosis, it is the leading cause of poor outcomes including death. Herein we review the major patterns of APS with a focus on the current management as well as potential approaches for improved outcomes for this most serious sarcoidosis phenotype.
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Affiliation(s)
- Rohit Gupta
- Temple University School of Medicine, 12314, Thoracic Medicine and Surgery, Philadelphia, Pennsylvania, United States;
| | - Marc A Judson
- Albany Medical College, 1092, Division of Pulmonary and Critical Care Medicine, Albany, New York, United States
| | - Robert P Baughman
- University of Cincinnati Medical Center, 24267, Medicine, Cincinnati, Ohio, United States
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4
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Ray A, Manikanta J, Singh K, Gabra P, Vyas S, Singh G, Xess I, Sethi P, Meena VP, Soneja M, Sinha S, Wig N, Kabra SK. An open-label non-inferiority randomised control trial comparing nebulised amphotericin B with oral itraconazole in patients with pulmonary aspergilloma. Mycoses 2021; 64:1038-1044. [PMID: 34058036 DOI: 10.1111/myc.13329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary aspergilloma (PA) is a common complication seen in patients with pulmonary tuberculosis sequelae. Antifungal therapy, including oral azoles, is commonly used though only surgical resection offers curative benefit. Local administration of amphotericin B, like intracavitary instillation, has been effective in aspergilloma patients though nebulised amphotericin B (nAB) has never been formally assessed. OBJECTIVE The aim of this prospective, non-inferior, open-label, randomised control trial is to evaluate the efficacy and safety of nebulised amphotericin B compared to oral itraconazole therapy in the treatment of PA. PATIENTS/METHODS Diagnosed cases of PA (n=33) were randomised into the control group receiving oral itraconazole (n=18) and intervention group receiving nebulised amphotericin B (n = 15). Response to treatment was assessed both clinically and radiologically at the end 6 months. RESULTS AND CONCLUSION The number of patients showing overall improvement at the end of 6 months in the control arm(oral itraconazole) vs intervention arm(nebulised amphotericin B) was 65% (95% CI 38.3-85.8) and 67%(95% CI 38.4%-88.2%), respectively, in the intention-to-treat and 79% (95% CI 49.2%-95.3%), and 65% (95% CI 38.4%-88.2%), respectively, in the per-protocol analysis. While there was no statistically significant difference between the intervention and control arm in both the analyses, non-inferiority was shown in the per-protocol but not in the intention-to-treat analysis. No major adverse events were noted in either group; however, a significant proportion of patients receiving nAB reported minor cough (40%), which, however, did not lead to discontinuation of therapy in any patients. Nebulised amphotericin B can be an effective therapeutic option for pulmonary aspergilloma patients.
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Affiliation(s)
- Animesh Ray
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jagdeesh Manikanta
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Komal Singh
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Pavan Gabra
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Surabhi Vyas
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Gagandeep Singh
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Immaculata Xess
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Prayas Sethi
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ved Prakash Meena
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Sinha
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - S K Kabra
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
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5
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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.
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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
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6
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Larkin PMK, Multani A, Beaird OE, Dayo AJ, Fishbein GA, Yang S. A Collaborative Tale of Diagnosing and Treating Chronic Pulmonary Aspergillosis, from the Perspectives of Clinical Microbiologists, Surgical Pathologists, and Infectious Disease Clinicians. J Fungi (Basel) 2020; 6:E106. [PMID: 32664547 PMCID: PMC7558816 DOI: 10.3390/jof6030106] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic pulmonary aspergillosis (CPA) refers to a spectrum of Aspergillus-mediated disease that is associated with high morbidity and mortality, with its true prevalence vastly underestimated. The diagnosis of CPA includes characteristic radiographical findings in conjunction with persistent and systemic symptoms present for at least three months, and evidence of Aspergillus infection. Traditionally, Aspergillus infection has been confirmed through histopathology and microbiological studies, including fungal culture and serology, but these methodologies have limitations that are discussed in this review. The treatment of CPA requires an individualized approach and consideration of both medical and surgical options. Most Aspergillus species are considered susceptible to mold-active triazoles, echinocandins, and amphotericin B; however, antifungal resistance is emerging and well documented, demonstrating the need for novel therapies and antifungal susceptibility testing that correlates with clinical response. Here, we describe the clinical presentation, diagnosis, and treatment of CPA, with an emphasis on the strengths and pitfalls of diagnostic and treatment approaches, as well as future directions, including whole genome sequencing and metagenomic sequencing. The advancement of molecular technology enables rapid and precise species level identification, and the determination of molecular mechanisms of resistance, bridging the clinical infectious disease, anatomical pathology, microbiology, and molecular biology disciplines.
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Affiliation(s)
- Paige M. K. Larkin
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (P.M.K.L.); (A.J.D.); (G.A.F.)
- Department of Pathology, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Ashrit Multani
- Department of Medicine, Division of Infectious Diseases, University of California Los Angeles, Los Angeles, CA 90095, USA; (A.M.); (O.E.B.)
| | - Omer E. Beaird
- Department of Medicine, Division of Infectious Diseases, University of California Los Angeles, Los Angeles, CA 90095, USA; (A.M.); (O.E.B.)
| | - Ayrton J. Dayo
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (P.M.K.L.); (A.J.D.); (G.A.F.)
| | - Gregory A. Fishbein
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (P.M.K.L.); (A.J.D.); (G.A.F.)
| | - Shangxin Yang
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (P.M.K.L.); (A.J.D.); (G.A.F.)
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Sehgal IS, Dhooria S, Muthu V, Prasad KT, Agarwal R. An overview of the available treatments for chronic cavitary pulmonary aspergillosis. Expert Rev Respir Med 2020; 14:715-727. [PMID: 32249630 DOI: 10.1080/17476348.2020.1750956] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Chronic pulmonary aspergillosis (CPA) is a chronic lung infection caused by Aspergillus fumigatus, that complicates structural lung diseases. Of the different types of CPA, chronic cavitary pulmonary aspergillosis (CCPA) is the most common form. The mainstay of treatment of CCPA is oral triazoles. However, many gaps exist in clinical decision-making about the agent of choice, the duration, and the assessment of treatment response. AREAS COVERED We discuss the approach to diagnosis and treatment of CCPA. We have searched the PubMed and EmBase databases (from inception till 31 October 2019) to identify studies describing the use of anti-fungal agents in CCPA. EXPERT OPINION Treatment for CCPA should be initiated with oral itraconazole for at least six months. In case of poor response or intolerance to itraconazole, voriconazole should be considered. Intravenous agents, including amphotericin B and echinocandins, may be used in those with either treatment failure or those who are intolerant to oral antifungal agents. Posaconazole and isavuconazole may be used as salvage therapy due to a better pharmacokinetic/pharmacodynamic profile of the former and reduced drug-drug interactions with the latter.
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Affiliation(s)
- 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
| | - Valliappan Muthu
- 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
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
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8
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Lang M, Lang AL, Chauhan N, Gill A. Non-surgical treatment options for pulmonary aspergilloma. Respir Med 2020; 164:105903. [DOI: 10.1016/j.rmed.2020.105903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 02/17/2020] [Indexed: 01/11/2023]
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Abstract
Sarcoidosis is a highly variable granulomatous multisystem syndrome. It affects individuals in the prime years of life; both the frequency and severity of sarcoidosis are greater in economically disadvantaged populations. The diagnosis, assessment, and management of pulmonary sarcoidosis have evolved as new technologies and therapies have been adopted. Transbronchial needle aspiration guided by endobronchial ultrasound has replaced mediastinoscopy in many centers. Advanced imaging modalities, such as fluorodeoxyglucose positron emission tomography scanning, and the widespread availability of magnetic resonance imaging have led to more sensitive assessment of organ involvement and disease activity. Although several new insights about the pathogenesis of sarcoidosis exist, no new therapies have been specifically developed for use in the disease. The current or proposed use of immunosuppressive medications for sarcoidosis has been extrapolated from other disease states; various novel pathways are currently under investigation as therapeutic targets. Coupled with the growing recognition of corticosteroid toxicities for managing sarcoidosis, the use of corticosteroid sparing anti-sarcoidosis medications is likely to increase. Besides treatment of granulomatous inflammation, recognition and management of the non-granulomatous complications of pulmonary sarcoidosis are needed for optimal outcomes in patients with advanced disease.
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Affiliation(s)
- Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, Department of Inflammation and Immunity, Lerner Research Institute Cleveland Clinic, Cleveland, OH, USA
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
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Denham ST, Wambaugh MA, Brown JCS. How Environmental Fungi Cause a Range of Clinical Outcomes in Susceptible Hosts. J Mol Biol 2019; 431:2982-3009. [PMID: 31078554 PMCID: PMC6646061 DOI: 10.1016/j.jmb.2019.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/18/2019] [Accepted: 05/01/2019] [Indexed: 12/11/2022]
Abstract
Environmental fungi are globally ubiquitous and human exposure is near universal. However, relatively few fungal species are capable of infecting humans, and among fungi, few exposure events lead to severe systemic infections. Systemic infections have mortality rates of up to 90%, cost the US healthcare system $7.2 billion annually, and are typically associated with immunocompromised patients. Despite this reputation, exposure to environmental fungi results in a range of outcomes, from asymptomatic latent infections to severe systemic infection. Here we discuss different exposure outcomes for five major fungal pathogens: Aspergillus, Blastomyces, Coccidioides, Cryptococcus, and Histoplasma species. These fungi include a mold, a budding yeast, and thermal dimorphic fungi. All of these species must adapt to dramatically changing environments over the course of disease. These dynamic environments include the human lung, which is the first exposure site for these organisms. Fungi must defend themselves against host immune cells while germinating and growing, which risks further exposing microbe-associated molecular patterns to the host. We discuss immune evasion strategies during early infection, from disruption of host immune cells to major changes in fungal cell morphology.
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Affiliation(s)
- Steven T Denham
- Division of Microbiology and Immunology, Pathology Department, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Morgan A Wambaugh
- Division of Microbiology and Immunology, Pathology Department, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Jessica C S Brown
- Division of Microbiology and Immunology, Pathology Department, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
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11
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Godet C, Alastruey-Izquierdo A, Flick H, Hennequin C, Mikilps-Mikgelbs R, Munteanu O, Page I, Seidel D, Salzer HJF. A CPAnet consensus statement on research priorities for chronic pulmonary aspergillosis: a neglected fungal infection that requires attention. J Antimicrob Chemother 2019; 73:280-286. [PMID: 29126309 DOI: 10.1093/jac/dkx390] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a severe fungal infection with a high morbidity and mortality, and is usually seen in immunocompetent patients with respiratory disorders. Clinical presentation is nonspecific and often overlaps with the symptoms and the radiological pattern caused by the underlying disease. Clinical management of CPA is further hampered by limited information about the epidemiology, disease dynamics, sensitivity and specificity of different mycological tests, mechanisms of antifungal resistance, efficient treatment and management strategies. In order to contribute to a better understanding and to improve CPA patient management and outcome, we established the Chronic Pulmonary Aspergillosis Network (CPAnet), a self-organized multinational research collaboration. Key research priorities, defined by using a modified Delphi process, include the establishment of a multinational web-based registry, the validation of different diagnostic tests, the establishment of a culture collection from samples of patients with proven CPA and the establishment of a consensus on a treatment outcome definition.
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Affiliation(s)
- Cendrine Godet
- CHU de Poitiers, Service des Maladies Infectieuses et Tropicales, Poitiers, France
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Holger Flick
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christophe Hennequin
- Sorbonne Universités, UPMC Université Paris 06, Inserm UMR S 1135, CNRS ERL 8255, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France.,AP-HP, Hôpital Saint-Antoine, Service de Parasitologie-Mycologie, Paris, France
| | | | - Oxana Munteanu
- State University of Medicine and Pharmacy 'Nicolae Testemitanu', Department of Internal Medicine, Division of Pneumology and Allergology, Chisinau, Republic of Moldova
| | - Iain Page
- National Aspergillosis Centre, University Hospital of South Manchester, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Danila Seidel
- Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Helmut J F Salzer
- Division of Clinical Infectious Diseases and German Centre for Infection Research Tuberculosis Unit, Research Centre Borstel, Borstel, Germany
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Affiliation(s)
- Debabrata Bandyopadhyay
- Division of Pulmonary and Critical Care Medicine, Geisinger Medical Center, Danville, PA, USA
| | - Marc A. Judson
- Division of Pulmonary and Critical Care Medicine, MC-91, Albany Medical College, Albany, NY, USA
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13
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Maghrabi F, Denning DW. The Management of Chronic Pulmonary Aspergillosis: The UK National Aspergillosis Centre Approach. CURRENT FUNGAL INFECTION REPORTS 2017; 11:242-251. [PMID: 29213345 PMCID: PMC5705730 DOI: 10.1007/s12281-017-0304-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose of Review Chronic pulmonary aspergillosis (CPA) is a serious long-term fungal disease of the lung with a worldwide prevalence. Treatment of CPA is not straightforward given the often-multiple associated co-morbidities, complex clinical picture, drug interactions, toxicities and intolerances. Recent Findings First line treatment is oral itraconazole or voriconazole. In the event of intolerance or toxicity, patients may be swapped from itraconazole to voriconazole or vice versa. In the event of resistance or further intolerance, third line treatment with posaconazole could be initiated. In those with pan-azole resistance, short-term courses of intravenous liposomal amphotericin B or micafungin are fourth line therapy, keeping in mind the nephrotoxic effects of amphotericin B. Summary The available evidence for current treatments in CPA is limited and based mostly on retrospective cohort studies. There is a real need to raise awareness of this devastating disease to enable early treatment as well as prospective drug trials and studies to identify potential patient factors that correlate with progression, severity and overall outcomes in order to target future therapies.
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Affiliation(s)
- Firas Maghrabi
- The National Aspergillosis Centre, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Southmoor Road, Manchester, M23 9LT UK
| | - David W Denning
- The National Aspergillosis Centre, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Southmoor Road, Manchester, M23 9LT UK
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14
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Muldoon EG, Strek ME, Patterson KC. Allergic and Noninvasive Infectious Pulmonary Aspergillosis Syndromes. Clin Chest Med 2017; 38:521-534. [PMID: 28797493 DOI: 10.1016/j.ccm.2017.04.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Aspergillus spp are ubiquitous in the environment, and inhalation of Aspergillus spores is unavoidable. An intact immune system, with normal airway function, protects most people from disease. Globally, however, the toll from aspergillosis is high. The literature has largely focused on invasive aspergillosis, yet the burden in terms of chronicity and prevalence is higher for noninvasive Aspergillus conditions. This article discusses allergic aspergilloses and provides an update on the diagnosis and management of allergic bronchopulmonary aspergillosis, including in patients with cystic fibrosis, and an update on severe asthma with fungal sensitization. In addition, the presentation, investigation, and management of noninvasive infectious aspergilloses are reviewed.
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Affiliation(s)
- Eavan G Muldoon
- National Aspergillosis Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK; Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
| | - Mary E Strek
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, 5481 South Maryland Avenue, Chicago, IL 60637, USA
| | - Karen C Patterson
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, 3400 Spruce Street, 828 West Gates Building, Philadelphia, PA 19104, USA
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15
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Jacobs SE, Saez-Lacy D, Wynkoop W, Walsh TJ. Successful Treatment of Allergic Bronchopulmonary Aspergillosis With Isavuconazole: Case Report and Review of the Literature. Open Forum Infect Dis 2017; 4:ofx040. [PMID: 28491888 PMCID: PMC5419068 DOI: 10.1093/ofid/ofx040] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 04/13/2017] [Indexed: 12/15/2022] Open
Abstract
Isavuconazole is a new triazole that is approved for primary therapy of invasive aspergillosis. We provide the first report of a patient with allergic bronchopulmonary aspergillosis (ABPA) who was successfully treated with isavuconazole with marked improvement and minimal adverse effects. We further review the literature on antifungal management of ABPA.
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Affiliation(s)
- Samantha E Jacobs
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York
| | | | | | - Thomas J Walsh
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York
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Agarwal R, Sehgal IS, Dhooria S, Aggarwal AN. Developments in the diagnosis and treatment of allergic bronchopulmonary aspergillosis. Expert Rev Respir Med 2016; 10:1317-1334. [PMID: 27744712 DOI: 10.1080/17476348.2016.1249853] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Allergic bronchopulmonary aspergillosis (ABPA) is a complex pulmonary disorder characterized by recurrent episodes of wheezing, fleeting pulmonary opacities and bronchiectasis. It is the most prevalent of the Aspergillus disorders with an estimated five million cases worldwide. Despite six decades of research, the pathogenesis, diagnosis and treatment of this condition remains controversial. The International Society for Human and Animal Mycology has formed a working group to resolve the controversies around this entity. In the year 2013, this group had proposed new criteria for diagnosis and staging, and suggested a treatment protocol for the management of this disorder. Since then, several pieces of new evidence have been published in the investigation and therapeutics of this condition. Areas covered: A non-systematic review of the available literature was performed. We summarize the current evidence in the evaluation and treatment of this enigmatic disorder. We suggest modifications to the existing criteria and propose a new scoring system for the diagnosis of ABPA. Expert commentary: All patients with asthma and cystic fibrosis should routinely be screened for ABPA using A. fumigatus-specific IgE levels. Glucocorticoids should be used as the first-line of therapy in ABPA, and itraconazole reserved in those with recurrent exacerbations and glucocorticoid-dependent disease.
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Affiliation(s)
- Ritesh Agarwal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Inderpaul S Sehgal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Sahajal Dhooria
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Ashutosh N Aggarwal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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Denning DW, Cadranel J, Beigelman-Aubry C, Ader F, Chakrabarti A, Blot S, Ullmann AJ, Dimopoulos G, Lange C. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. Eur Respir J 2016; 47:45-68. [PMID: 26699723 DOI: 10.1183/13993003.00583-2015] [Citation(s) in RCA: 529] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Chronic pulmonary aspergillosis (CPA) is an uncommon and problematic pulmonary disease, complicating many other respiratory disorders, thought to affect ~240 000 people in Europe. The most common form of CPA is chronic cavitary pulmonary aspergillosis (CCPA), which untreated may progress to chronic fibrosing pulmonary aspergillosis. Less common manifestations include: Aspergillus nodule and single aspergilloma. All these entities are found in non-immunocompromised patients with prior or current lung disease. Subacute invasive pulmonary aspergillosis (formerly called chronic necrotising pulmonary aspergillosis) is a more rapidly progressive infection (<3 months) usually found in moderately immunocompromised patients, which should be managed as invasive aspergillosis. Few clinical guidelines have been previously proposed for either diagnosis or management of CPA. A group of experts convened to develop clinical, radiological and microbiological guidelines. The diagnosis of CPA requires a combination of characteristics: one or more cavities with or without a fungal ball present or nodules on thoracic imaging, direct evidence of Aspergillus infection (microscopy or culture from biopsy) or an immunological response to Aspergillus spp. and exclusion of alternative diagnoses, all present for at least 3 months. Aspergillus antibody (precipitins) is elevated in over 90% of patients. Surgical excision of simple aspergilloma is recommended, if technically possible, and preferably via video-assisted thoracic surgery technique. Long-term oral antifungal therapy is recommended for CCPA to improve overall health status and respiratory symptoms, arrest haemoptysis and prevent progression. Careful monitoring of azole serum concentrations, drug interactions and possible toxicities is recommended. Haemoptysis may be controlled with tranexamic acid and bronchial artery embolisation, rarely surgical resection, and may be a sign of therapeutic failure and/or antifungal resistance. Patients with single Aspergillus nodules only need antifungal therapy if not fully resected, but if multiple they may benefit from antifungal treatment, and require careful follow-up.
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Affiliation(s)
- David W Denning
- The National Aspergillosis Centre, University Hospital of South Manchester, The University of Manchester and the Manchester Academic Health Science Centre, Manchester, UK
| | - Jacques Cadranel
- Service de Pneumologie, AP-HP, Hôpital Tenon and Sorbonne Université, UPMC Univ Paris 06, Paris, France
| | | | - Florence Ader
- Dept of Infectious Diseases, Hospices Civils de Lyon, Lyon, France Centre International de Recherche en Infectiologie (CIRI), INSERM U1111, CNRS UMR5308, Lyon, France
| | - Arunaloke Chakrabarti
- Center of Advanced Research in Medical Mycology, Dept of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Stijn Blot
- Dept of Internal Medicine, Ghent University, Ghent, Belgium Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia
| | - Andrew J Ullmann
- Dept of Internal Medicine II, Division of Infectious Diseases, University Hospital Würzburg, Julius-Maximilians-University, Würzburg, Germany
| | - George Dimopoulos
- Dept of Critical and Respiratory Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece
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Hayes GE, Novak-Frazer L. Chronic Pulmonary Aspergillosis-Where Are We? and Where Are We Going? J Fungi (Basel) 2016; 2:jof2020018. [PMID: 29376935 PMCID: PMC5753080 DOI: 10.3390/jof2020018] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/19/2016] [Accepted: 06/01/2016] [Indexed: 02/06/2023] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is estimated to affect 3 million people worldwide making it an under recognised, but significant health problem across the globe, conferring significant morbidity and mortality. With variable disease forms, high levels of associated respiratory co-morbidity, limited therapeutic options and prolonged treatment strategies, CPA is a challenging disease for both patients and healthcare professionals. CPA can mimic smear-negative tuberculosis (TB), pulmonary histoplasmosis or coccidioidomycosis. Cultures for Aspergillus are usually negative, however, the detection of Aspergillus IgG is a simple and sensitive test widely used in diagnosis. When a fungal ball/aspergilloma is visible radiologically, the diagnosis has been made late. Sometimes weight loss and fatigue are predominant symptoms; pyrexia is rare. Despite the efforts of the mycology community, and significant strides being taken in optimising the care of these patients, much remains to be learnt about this patient population, the disease itself and the best use of available therapies, with the development of new therapies being a key priority. Here, current knowledge and practices are reviewed, and areas of research priority highlighted.
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Affiliation(s)
- Gemma E Hayes
- The University of Manchester, Oxford Road, Manchester M13 9PL, UK.
- Manchester Academic Health Science Centre, 46 Grafton Street, Manchester M13 9NT, UK.
- National Aspergillosis Centre, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Southmoor Road, Manchester M23 9LT, UK.
| | - Lilyann Novak-Frazer
- The University of Manchester, Oxford Road, Manchester M13 9PL, UK.
- Manchester Academic Health Science Centre, 46 Grafton Street, Manchester M13 9NT, UK.
- The University of Manchester, Manchester Academic Health Science Centre, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Southmoor Road, Manchester M23 9LT, UK.
- Mycology Reference Centre, Manchester, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Southmoor Road, Manchester M23 9LT, UK.
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20
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Izumikawa K. Recent advances in chronic pulmonary aspergillosis. Respir Investig 2016; 54:85-91. [PMID: 26879477 DOI: 10.1016/j.resinv.2015.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 10/06/2015] [Accepted: 10/22/2015] [Indexed: 06/05/2023]
Abstract
Chronic pulmonary aspergillosis (CPA) is a slowly progressing pulmonary syndrome caused by Aspergillus spp. Specific knowledge regarding the disease entity, diagnosis method, and management is needed. This review focuses on the recent advances in our understanding of CPA. A new clinical disease entity of chronic progressive pulmonary aspergillosis consisting of chronic necrotizing pulmonary aspergillosis and chronic cavitary pulmonary aspergillosis is proposed. Although newer antifungals are not available, evidence describing the treatment of CPA is accumulating. Longer administration of azoles is required for a better prognosis, but there is a risk of inducing azole resistance. Therapeutic drug monitoring and patient education are required. Establishing a drug-susceptibility test that can be performed in the general laboratory and the referral center are also important. Although the number of publications regarding CPA is growing, there are still many unanswered questions. Additional evidence and translational research regarding diagnosis, management, and drug resistance are urgently needed to improve the outcome of CPA.
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Affiliation(s)
- Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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21
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Godet C, Laurent F, Bergeron A, Ingrand P, Beigelman-Aubry C, Camara B, Cottin V, Germaud P, Philippe B, Pison C, Toper C, Carette MF, Frat JP, Béraud G, Roblot F, Cadranel J. CT Imaging Assessment of Response to Treatment in Chronic Pulmonary Aspergillosis. Chest 2016; 150:139-47. [PMID: 26905365 DOI: 10.1016/j.chest.2016.02.640] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 12/09/2015] [Accepted: 02/02/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Long-term antifungal therapy is usually the only treatment option for chronic pulmonary aspergillosis. However, response rates are difficult to compare because the reported clinical, mycologic, or radiologic criteria are not standardized. Objective parameters are therefore needed. To define the most relevant CT imaging variables in assessment of response to treatment, we investigated changes over time in CT imaging variables. METHODS Changes in CT imaging variables were assessed by systematic analysis of the CT scan findings of 36 patients at diagnosis and 6 months after initiation of treatment. The relevant radiologic variables were determined by selecting those showing significant changes over time. Two experienced thoracic radiologists, blinded for clinical and serologic response, independently performed CT scan analyses. Interreader agreement and concordance between radiologic and clinical response were evaluated. RESULTS Of the 36 patients, seven experienced clinical deterioration while undergoing therapy. Significantly evolving radiologic variables included cavity and pleural wall thickening (P < .05), which were associated with clinical improvement. There was a strong association between fungus ball disappearance and cavity/pleural wall thickening reduction and clinical improvement (P = .04). There was poor agreement between size changes of cavities or nodules, and clinical evolution (Cohen's κ, -0.13 to -0.24). CONCLUSIONS Variations in cavity and pleural wall thickness may be the most relevant CT imaging variables for assessing response to treatment. Loss of fungus ball is strongly associated with clinical and radiologic improvement, but cavity size changes are unrelated to chronic pulmonary aspergillosis evolution. All these CT imaging variables may be applied in future clinical trials to assess treatment outcome.
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Affiliation(s)
- Cendrine Godet
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France.
| | - François Laurent
- Service d'Imagerie Médicale, Radiologie Diagnostique et Thérapeutique, Centre de Recherche Cardio-Thoracique, Université Bordeaux, Bordeaux, France; CHU de Bordeaux, Service d'Imagerie Médicale, Radiologie Diagnostique et Thérapeutique, and Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Centre de Recherche Cardio-Thoracique, Université Bordeaux, Bordeaux, France
| | - Anne Bergeron
- Service de Pneumologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Diderot, Paris, France; Biostatistics and Clinical Epidemiology Research Team, Unité Mixte de Recherche (UMR) 1153, Centre de Recherche en Epidémiologie et Statistique de Sorbonne Paris Cité (CRESS), Université Paris Diderot, Paris, France
| | - Pierre Ingrand
- Epidemiology and Biostatistics, INSERM Centre d'Investigation Clinique (CIC) 1402, Poitiers University Hospital, Poitiers, France
| | - Catherine Beigelman-Aubry
- Service de Radiodiagnostic et Radiologie Interventionnelle, Centre Hospitalier Universitaire Vaudois (CHUV) Lausanne, Lausanne, Switzerland
| | - Boubou Camara
- Pôle Thorax et Vaisseaux, Clinique Universitaire de Pneumologie, CHU de Grenoble, Grenoble, France
| | - Vincent Cottin
- Service de Pneumologie, Centre National de Référence des Maladies Pulmonaires Rares, CHU de Lyon, Hôpital Louis Pradel, Lyon, France; UMR754, Université Claude Bernard Lyon 1, Lyon, France
| | | | - Bruno Philippe
- Service de Pneumologie, Hôpital René Dubos, Centre Hospitalier Pontoise, Pontoise, France
| | - Christophe Pison
- Pôle Thorax et Vaisseaux, Clinique Universitaire de Pneumologie, CHU de Grenoble, Grenoble, France; Université Grenoble Alpes, Saint-Martin-d'Hères, France; INSERM 1055, Grenoble, France
| | - Cécile Toper
- Service de Pneumologie, Hôpital Tenon, AP-HP, Paris, France
| | - Marie France Carette
- Service de Radiologie, Hôpital Tenon, AP-HP, Paris, France; Université Pierre et Marie Curie (UPMC), Université Paris 06, Sorbonne Université, Paris, France
| | - Jean-Pierre Frat
- Service de Réanimation Médicale, CHU de Poitiers, Poitiers, France; INSERM, CIC 1402, Université de Poitiers, Poitiers, France
| | - Guillaume Béraud
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France; EA2694, Université Droit et Santé Lille 2, Lille, France; Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Hasselt, Belgium
| | - France Roblot
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France; U1070 INSERM, Poitiers, France
| | - Jacques Cadranel
- Service de Pneumologie, Hôpital Tenon, AP-HP, Paris, France; Université Pierre et Marie Curie (UPMC), Université Paris 06, Sorbonne Université, Paris, France
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Evaluation of the Double Agar Gel Immunodiffusion Test and of the Enzyme-Linked Immunosorbent Assay in the Diagnosis and Follow-Up of Patients with Chronic Pulmonary Aspergillosis. PLoS One 2015; 10:e0134841. [PMID: 26271000 PMCID: PMC4536220 DOI: 10.1371/journal.pone.0134841] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/15/2015] [Indexed: 11/26/2022] Open
Abstract
The diagnosis of chronic pulmonary aspergillosis (CPA) depends on the radiologic image and the identification of specific antibodies. The present study aimed to evaluate accuracy parameters of enzyme-linked immunosorbent assay (ELISA) and of the determination of serum galactomannan level in the diagnosis of patients with CPA, comparing these results with the double agar gel immunodiffusion (DID) test. In addition, the prevalence of cross-reactivity and the serological progression after treatment were evaluated by comparing DID and ELISA. Six study groups were formed: G1: 22 patients with CPA, 17 of whom had Aspergillus fungus ball, one chronic cavitary pulmonary aspergillosis (CCPA) and four chronic fibrosing pulmonary aspergillosis (CFPA); G2: 28 patients with pulmonary tuberculosis (TB); G3: 23 patients with histoplasmosis (HST); G4: 50 patients with paracoccidioidomycosis (PCM); G5: 20 patients with cryptococcosis (CRC); and G6: 200 healthy controls. Serum antibodies were measured by DID and ELISA, with two antigen preparations—Aspergillus fumigatus (DID1, ELISA1) and a pool of A. fumigatus, A. flavus and A. niger antigens (DID2, ELISA2). The Platélia Aspergillus Enzyme Immunoassay (EIA) kit was used to measure galactomannan. The cut-off points of ELISA were determined for each antigen preparation and for the 95% and 99% confidence intervals. Despite the low sensitivity, DID was the technique of choice due to its specificity, positive and negative predictive values and positive likelihood ratio–especially with the antigen pool and due to the low frequency of cross-reactivity. ELISA1 and a 0.090 cut-off showed high sensitivity, specificity and negative predictive value, but a high frequency of cross-reactivity with CRC. The best degree of agreement was observed between ELISA1 and ELISA2. The detection of serum galactomannan showed high sensitivity, comparable to ELISA2. The immunodiffusion test showed an excellent relationship with the progression after treatment, which made it the reaction of choice for patient follow-up.
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Maturu VN, Agarwal R. Itraconazole in chronic pulmonary aspergillosis: In whom, for how long, and at what dose? Lung India 2015; 32:309-12. [PMID: 26180377 PMCID: PMC4502192 DOI: 10.4103/0970-2113.159523] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Venkata Nagarjuna Maturu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India E-mail:
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India E-mail:
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Abstract
Itraconazole (Sporanox) is a triazole antifungal agent with a broad activity spectrum and favorable pharmacokinetic and safety profiles. Numerous clinical trials have established the efficacy and safety of itraconazole in the treatment of superficial fungal infections. In this field, full exploitation of its pharmacokinetics in keratinized tissues has led to the development of intermittent (pulse) treatment regimens that allow similar efficacy with lower overall drug exposure as well as a reduction in treatment costs. The additional anti-inflammatory action of itraconazole also makes it suitable for application in difficult-to-treat inflammatory skin disorders, such as seborrheic dermatitis. Recently, a new oral liquid formulation and an intravenous formulation have been developed, extending the therapeutic application of itraconazole to systemic fungal infections. Due to its broad activity spectrum and excellent tolerability, itraconazole is a valuable addition to the antifungal armamentarium used for prophylactic and empiric treatment in immunocompromised hosts.
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Affiliation(s)
- R Caputo
- Institute of Dermatological Sciences, University of Milan, IRCCS Ospedale Maggiore of Milan, Milan, Italy.
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25
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Godet C, Philippe B, Laurent F, Cadranel J. Chronic Pulmonary Aspergillosis: An Update on Diagnosis and Treatment. Respiration 2014; 88:162-74. [DOI: 10.1159/000362674] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 04/01/2014] [Indexed: 11/19/2022] Open
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Jhun BW, Jeon K, Eom JS, Lee JH, Suh GY, Kwon OJ, Koh WJ. Clinical characteristics and treatment outcomes of chronic pulmonary aspergillosis. Med Mycol 2013; 51:811-7. [PMID: 23834282 DOI: 10.3109/13693786.2013.806826] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a relatively uncommon disease that has been poorly characterized. This study investigated the clinical features and treatment outcomes of CPA through a retrospective review of records of patients with newly diagnosed CPA between January 2008 and January 2012. A total of 70 CPA patients, which included 51 (73%) males, had a median age of 55 years. Fifty-seven patients (81%) had a history of pulmonary tuberculosis and pulmonary disease caused by nontuberculous mycobacteria (NTM) was a primary underlying condition in 32 patients (46%). Most patients (n = 66; 99%) were treated with oral itraconazole, for a median of 6.4 months. Treatment response of 73% of patients was based on alleviation of symptoms and in 44% on computed tomography. Laboratory tests improved for more than 60% of patients and overall favorable responses were achieved in 44 patients (62%). Five of the latter (11%) had to restart antifungal therapy after a median of 9.2 months after therapy. Death occurred in 10 patients (14%). This study suggested that NTM lung disease was an important risk factor for CPA development. While treatment with oral itraconazole for approximately 6 months was moderately effective in treating CPA, a more effective treatment is required.
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Affiliation(s)
- Byung Woo Jhun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
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Kravitz JN, Berry MW, Schabel SI, Judson MA. A Modern Series of Percutaneous Intracavitary Instillation of Amphotericin B for the Treatment of Severe Hemoptysis From Pulmonary Aspergilloma. Chest 2013; 143:1414-1421. [DOI: 10.1378/chest.12-1784] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Agarwal R, Vishwanath G, Aggarwal AN, Garg M, Gupta D, Chakrabarti A. Itraconazole in chronic cavitary pulmonary aspergillosis: a randomised controlled trial and systematic review of literature. Mycoses 2013; 56:559-70. [DOI: 10.1111/myc.12075] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 01/30/2013] [Accepted: 02/23/2013] [Indexed: 01/12/2023]
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine; Postgraduate Institute of Medical Education and Research; Chandigarh; India
| | - Gella Vishwanath
- 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
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging; Postgraduate Institute of Medical Education and Research; Chandigarh; India
| | - Dheeraj Gupta
- Department of Pulmonary Medicine; Postgraduate Institute of Medical Education and Research; Chandigarh; India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology; Postgraduate Institute of Medical Education and Research; Chandigarh; India
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Abstract
Chronic pulmonary aspergillosis (CPA) is a relatively rare, slowly progressive pulmonary syndrome caused by Aspergillus spp. The scarcity of clinical evidence for its management is an important issue. Oral azoles are recommended as the primary treatment of CPA; however, the evidence for their effectiveness is insufficient. Azole-resistant A. fumigatus is rapidly increasing and becoming a serious concern. Because long-term administration of azoles is the mainstay of CPA, azole resistance may pose a serious threat. Furthermore, prolonged oral administration of azoles may lead to increased azole resistance in CPA patients. Therefore, alternative management strategies for CPA must be considered, and one option may involve the use of intravenous antifungals such as echinocandins and polyens. The utility of these antifungals, however, has not been well evaluated and remains controversial because the drugs are expensive and require patients to be admitted to the hospital for their use. New antifungal drugs with novel mechanisms of action are also needed.
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Affiliation(s)
- Koichi Izumikawa
- Department of Molecular Microbiology and Immunology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
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Nakamoto K, Takayanagi N, Kanauchi T, Ishiguro T, Yanagisawa T, Sugita Y. Prognostic factors in 194 patients with chronic necrotizing pulmonary aspergillosis. Intern Med 2013; 52:727-34. [PMID: 23545666 DOI: 10.2169/internalmedicine.52.9142] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The prognostic factors of chronic necrotizing pulmonary aspergillosis remain unclear. We assessed the prognostic factors of all-cause mortality in patients with chronic necrotizing pulmonary aspergillosis, focusing especially on underlying pulmonary disease, first-line treatment and host predisposition. METHODS We retrospectively analyzed the medical records of 194 patients negative for HIV who had chronic necrotizing pulmonary aspergillosis treated at our institution in Saitama, Japan. RESULTS The patients (median age, 68.5 years) were followed over a median follow-up time of 2.6 years. The underlying pulmonary diseases consisted of previous pulmonary tuberculosis in 59 (30.4%) patients, emphysema in 39 (20.1%) patients, interstitial lung disease in 32 (16.5%) patients, nontuberculous mycobacteriosis in 29 (14.9%) patients and other diseases in 35 (18%) patients. The first-line treatments included observation in 65 (33.5%) patients, itraconazole in 56 (28.9%) patients, micafungin in 46 (23.7%) patients, voriconazole in 22 (11.3%) patients and amphotericin B (including liposomal amphotericin B) in five (2.6%) patients. The overall cumulative mortality rate was 50.2% at five years and 67.4% at 10 years. Multivariate Cox proportional hazard modeling found an older age, the presence of systemic comorbidities, baseline corticosteroid use, a body mass index of <18.5 kg/m(2) and a C-reactive protein level of ≥5.0 mg/dL to be negative prognostic factors for all-cause mortality. CONCLUSION The 5-year mortality rate of chronic necrotizing pulmonary aspergillosis was 50.2%. When clinical trials are designed and implemented to test effective drug therapies in patients with chronic necrotizing pulmonary aspergillosis, the trial patients should be stratified according to these prognostic factors prior to randomization.
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Affiliation(s)
- Keitaro Nakamoto
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan.
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Phase behavior of itraconazole-phenol mixtures and its pharmaceutical applications. Int J Pharm 2012; 436:652-8. [PMID: 22871560 DOI: 10.1016/j.ijpharm.2012.07.054] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 06/29/2012] [Accepted: 07/24/2012] [Indexed: 11/21/2022]
Abstract
The aims of this study were to examine the phase behavior of itraconazole-phenol mixtures and assess the feasibility of topical formulations of itraconazole using eutectic mixture systems. Itraconazole-phenol eutectic mixtures were characterized using differential scanning calorimetry, Fourier transform infrared spectroscopy, (1)H-nuclear magnetic resonance, and powder X-ray diffractometry. The skin permeation rates of itraconazole-phenol eutectic formulations were determined using Franz diffusion cells fitted with excised hairless mouse skins. Itraconazole can form eutectic compounds with phenol, and the hydrogen-bonding interactions between the carbonyl group in the itraconazole and hydroxyl group in phenol play a major role in itraconazole-phenol eutectic formation. Despite its high molecular weight and hydrophobicity, the drug (i.e., itraconazole) can be permeated through excised hairless mouse skins from itraconazole-phenol eutectic formulations. The findings of this study emphasize the capabilities of the topical application of itraconazole via external preparations.
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Cadranel J, Philippe B, Hennequin C, Bergeron A, Bergot E, Bourdin A, Cottin V, Jeanfaivre T, Godet C, Pineau M, Germaud P. Voriconazole for chronic pulmonary aspergillosis: a prospective multicenter trial. Eur J Clin Microbiol Infect Dis 2012; 31:3231-9. [PMID: 22782438 PMCID: PMC3479377 DOI: 10.1007/s10096-012-1690-y] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 06/21/2012] [Indexed: 11/28/2022]
Abstract
Early evidence suggests the efficacy of voriconazole for chronic pulmonary aspergillosis (CPA). We conducted a prospective, open, multicenter trial to evaluate the efficacy and safety of voriconazole for proven CPA in minimally or non-immunocompromised patients. Patients had CPA confirmed by chest computed tomography (CT) and/or endoscopy, positive Aspergillus culture from a respiratory sample, and positive serologic test for Aspergillus precipitins. Patients received voriconazole (200 mg twice daily) for a period of 6-12 months and were followed for 6 months after the end of therapy (EOT). The primary endpoint was global success at 6 months, defined as complete or partial (≥50 % improvement) radiological response and mycological eradication. Forty-one patients with confirmed CPA were enrolled. All patients had A. fumigatus as the etiologic agent. By EOT, five patients had died from comorbidities and seven had discontinued voriconazole due to toxicity. The global success rate at 6 months was 13/41 (32 %): 10/19 (53 %) for chronic necrotizing aspergillosis and 3/22 (14 %) for chronic cavitary aspergillosis (p = 0.01). The respective success rates at EOT were 58 and 32 %. Clinical symptoms and quality of life also improved during treatment. Voriconazole is effective for CPA, with acceptable toxicity. The response rate is higher and obtained more rapidly in necrotizing than cavitary forms.
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Affiliation(s)
- J Cadranel
- Service de Pneumologie et Réanimation, AP-HP, Hôpital Tenon, 4 Rue de la Chine, 75020, Paris, France.
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Ohba H, Miwa S, Shirai M, Kanai M, Eifuku T, Suda T, Hayakawa H, Chida K. Clinical characteristics and prognosis of chronic pulmonary aspergillosis. Respir Med 2012; 106:724-9. [PMID: 22349065 DOI: 10.1016/j.rmed.2012.01.014] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 01/16/2012] [Accepted: 01/31/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The details of the clinical characteristics of patients with chronic pulmonary aspergillosis (CPA) have not been fully understood. METHOD One hundred twenty-nine consecutive patients with isolation of Aspergillus species by culture from respiratory specimens who attended our hospital between October 2001 and September 2009 were enrolled. Patients diagnosed with chronic pulmonary aspergillosis (CPA) were retrospectively reviewed for clinical characteristics and prognosis, compared with patients with Aspergillus species colonization. RESULTS Forty-two (32.6%) were diagnosed with CPA, whereas 87 (67.4%) with colonization. Aspergillus fumigatus was significantly more frequently detected in the CPA group than in the colonization group. Regarding underlying diseases, CPA patients had a significantly higher prevalence of a history of pulmonary tuberculosis and diabetes mellitus than colonization patients. There were no significant differences between the CPA and colonization group in Aspergillus antigen titers. Positivity for Aspergillus precipitating antibody was 74.3% in CPA and 15.8% in colonization, respectively. Sensitivity and specificity of Aspergillus precipitating antibody for the determination of CPA was 74.4% and 84.1%, respectively.Patients with CPA had significantly shorter survival than patients with colonization (mortality rate 50.0% vs. 13.8%, observation periods: 28.7 ± 26.6 months) (p < 0.0001). Multivariable analysis revealed that BMI was an independent predictor of prognosis (Odds Ratio, 1.973; p = 0.0223). CONCLUSIONS CPA is a disease with a poor prognosis, which shows distinct clinical characteristics from colonization.
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Affiliation(s)
- Hisano Ohba
- Department of Respiratory Medicine, Tenryu Hospital, National Hospital Organization, 4201-2, Hamamatsu 434-8511, Japan
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Chronic aspergillus infections of the respiratory tract: diagnosis, management and antifungal resistance. Curr Opin Infect Dis 2011; 23:584-9. [PMID: 20827190 DOI: 10.1097/qco.0b013e32833ed694] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Chronic pulmonary aspergillosis (CPA) is a relatively rare, slowly progressive pulmonary syndrome due to Aspergillus spp. that requires specific knowledge in terms of disease entity, diagnosis, management and azole resistance. This review focuses on the recent understanding of CPA entity and the emergence of azole resistance in CPA. RECENT FINDINGS Due to complexities related to patients' background and limited pathological evidence, the disease entity of CPA was incomprehensive and numerous names were previously used. The disease entities and nomenclature of subtypes of CPA have recently been proposed, though previous literature had grouped several different forms of CPA together. Recent advances in the methodology of susceptibility testing have indicated increasing azole resistance in Aspergillus spp. CPA is potentially involved in producing azole resistance and associated with poor response to azoles. SUMMARY As there are few publications regarding CPA, there are still many unanswered questions. However, updating of disease entity will promote the clinical and basic research in this field. Moreover, the emergence of antifungal drug resistance of Aspergillus is becoming a major concern. Thus, more evidence and research regarding drug resistance are required to improve the outcome of CPA.
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Pena TA, Soubani AO, Samavati L. Aspergillus lung disease in patients with sarcoidosis: a case series and review of the literature. Lung 2011; 189:167-72. [PMID: 21327836 DOI: 10.1007/s00408-011-9280-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 01/20/2011] [Indexed: 11/28/2022]
Abstract
Chronic cavitary pulmonary aspergillosis (CCPA) has been associated with advanced lung diseases. Pulmonary sarcoidosis, a granulomatous inflammatory disorder, is associated with CCPA. We identified CCPA in 2% of cases in a large cohort of sarcoidosis patients. We found a lack of response to medical treatment and poor outcome in this subgroup.
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Affiliation(s)
- Tahuanty A Pena
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Wayne State University School of Medicine, 3990 John R, 3 Hudson, Detroit, MI 48201, USA
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Baughman RP, Nunes H. Complicated Sarcoidosis: Challenges in Dealing with Severe Manifestations. Autoimmune Dis 2011. [DOI: 10.1007/978-0-85729-358-9_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Chudasama A, Patel V, Nivsarkar M, Vasu K, Shishoo C. Investigation of microemulsion system for transdermal delivery of itraconazole. J Adv Pharm Technol Res 2011; 2:30-8. [PMID: 22171289 PMCID: PMC3217682 DOI: 10.4103/2231-4040.79802] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A new oil-in-water microemulsion-based (ME) gel containing 1% itraconazole (ITZ) was developed for topical delivery. The solubility of ITZ in oils and surfactants was evaluated to identify potential excipients. The microemulsion existence ranges were defined through the construction of the pseudoternary phase diagrams. The optimized microemulsion was characterized for its morphology and particle size distribution. The optimized microemulsion was incorporated into polymeric gels of Lutrol F127, Xanthan gum, and Carbopol 934 for convenient application and evaluated for pH, drug content, viscosity, and spreadability. In vitro drug permeation of ME gels was determined across excised rat skins. Furthermore, in vitro antimycotic inhibitory activity of the gels was conducted using agar-cup method and Candida albicans as a test organism. The droplet size of the optimized microemulsion was found to be <100 nm. The optimized Lutrol F 127 ME gel showed pH in the range of 5.68±0.02 and spreadability of 5.75±1.396 gcm/s. The viscosity of ME gel was found to be 1805.535±542.4 mPa s. The permeation rate (flux) of ITZ from prepared ME gel was found to be 4.234 μg/cm/h. The release profile exhibited diffusion controlled mechanism of drug release from ME ITZ gel. The developed ME gels were nonirritant and there was no erythema or edema. The antifungal activity of ITZ showed the widest zone of inhibition with Lutrol F127 ME gel. These results indicate that the studied ME gel may be a promising vehicle for topical delivery of ITZ.
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Affiliation(s)
- Arpan Chudasama
- Department of Pharmaceutics, B V Patel PERD Centre, Ahmedabad, Gujarat, India
| | - Vineetkumar Patel
- Department of Pharmaceutics, B V Patel PERD Centre, Ahmedabad, Gujarat, India
| | - Manish Nivsarkar
- Department of Pharmacology & Toxicology, B V Patel PERD Centre, Ahmedabad, Gujarat, India
| | - Kamala Vasu
- Department of Medicinal Chemistry, B V Patel PERD Centre, Ahmedabad, Gujarat, India
| | - Chamanlal Shishoo
- Department of Pharmaceutics, B V Patel PERD Centre, Ahmedabad, Gujarat, India
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TOMIOKA H, KANEDA T, KIDA Y, KANEKO M, FUJII H, HAYASHI M, TOMII K, TADA K, SUZUKI Y, KARINO T. An Open, Noncomparative Multicenter Study of the Efficacy and Safety of Itraconazole Injections and High Dose Capsules in Chronic Pulmonary Aspergillosis. ACTA ACUST UNITED AC 2011; 85:644-51. [PMID: 22250455 DOI: 10.11150/kansenshogakuzasshi.85.644] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Hiromi TOMIOKA
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital
| | - Toshihiko KANEDA
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital
| | - Yoko KIDA
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital
| | - Masahiro KANEKO
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital
| | - Hiroshi FUJII
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital
| | - Michio HAYASHI
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital
| | - Keisuke TOMII
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital
| | - Kimihide TADA
- Department of Respiratory Medicine, Nishi-Kobe Medical Center
| | | | - Takayuki KARINO
- Department of Respiratory Medicine, Shinko Hospital, 5) Department of Respiratory Medicine, National Hospital Organization, Hyogo Central Hospital
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Abstract
The incidence of invasive aspergillosis is increasing rapidly in the developed world with two Aspergillus spp., A. fumigatus and A. flavus, causing the majority of infections (85-90% and 5-10%, respectively). The major risk factors are profound neutropenia (< or =1000 x 10(6) cells/L), prolonged neutropenia, neutrophil function deficits, and corticosteroid therapy. Useful diagnostic techniques include sputum culture, CT scan, bronchoscopy with microscopy and culture, percutaneous lung biopsy, open lung biopsy and serology. Invasive aspergillosis has an almost 100% mortality rate if untreated. Amphotericin B is the usual first-line therapy although it is associated with a high failure rate. Itraconazole (> or =400 mg daily) is a useful alternative and surgical resection may be life saving in some cases. The efficacy of the initial therapy is critical for improving mortality rates.
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Affiliation(s)
- D W Denning
- Department of Infections Diseases and Tropical Medicine, North Manchester General Hospital, Manchester, M8 6RB, UK
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40
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Nam HS, Jeon K, Um SW, Suh GY, Chung MP, Kim H, Kwon OJ, Koh WJ. Clinical characteristics and treatment outcomes of chronic necrotizing pulmonary aspergillosis: a review of 43 cases. Int J Infect Dis 2010; 14:e479-82. [DOI: 10.1016/j.ijid.2009.07.011] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Accepted: 07/23/2009] [Indexed: 10/20/2022] Open
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Pasqualotto AC, Powell G, Niven R, Denning DW. The effects of antifungal therapy on severe asthma with fungal sensitization and allergic bronchopulmonary aspergillosis. Respirology 2010; 14:1121-7. [PMID: 19909460 DOI: 10.1111/j.1440-1843.2009.01640.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Very little is known about the response rates to or appropriateness of treatment for patients with allergic fungal diseases of the lung. This study assessed the effect of antifungal therapy in patients with severe asthma with fungal sensitization (SAFS) and allergic bronchopulmonary aspergillosis (ABPA). METHODS A retrospective cohort study of 33 adult patients who fulfilled the criteria for either SAFS (n = 22) or ABPA (n = 11) was conducted. All patients had received antifungal therapy for at least 6 months. The primary study end point was the effect of antifungal therapy on patients' lung function. RESULTS Overall, total IgE values and radioallergosorbent test (RAST) for A. fumigatus markedly decreased after 6 months of therapy in both SAFS and ABPA patients (P = 0.004 and P = 0.005, respectively). Reduction was seen in the eosinophil count (P = 0.037), dose of oral steroids (P = 0.043) and courses of systemic steroids required (P = 0.041). Lung function also improved (P = 0.016). Four of 10 patients discontinued oral steroids after 6 months of therapy. Reduction in IgE levels (P = 0.015) and RAST for A. fumigatus was also observed (P = 0.006) for those patients treated for at least 1 year with antifungal drugs. CONCLUSIONS Both ABPA and SAFS patients benefited from oral antifungal therapy. The antifungal therapy may act by reducing the antigenic load, interacting with corticosteroids or by a direct immunological effect.
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Abstract
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.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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43
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Wark PAB, Gibson PG. Allergic bronchopulmonary aspergillosis: New concepts of pathogenesis and treatment. Respirology 2008. [DOI: 10.1111/j.1440-1843.2001.00289.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Peter A. B. Wark
- Airways Research Centre, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Peter G. Gibson
- Airways Research Centre, John Hunter Hospital, Newcastle, New South Wales, Australia
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44
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Pulmonale Hohlraumbildungen, Myzetome und Hämoptysen. Wien Med Wochenschr 2007; 157:466-72. [DOI: 10.1007/s10354-007-0460-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2007] [Accepted: 06/19/2007] [Indexed: 11/25/2022]
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Rhee YS, Park CW, Nam TY, Shin YS, Chi SC, Park ES. Formulation of parenteral microemulsion containing itraconazole. Arch Pharm Res 2007; 30:114-23. [PMID: 17328251 DOI: 10.1007/bf02977787] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The aim of this study was to develop an aqueous parenteral formulation containing itraconazole (ITZ) using an o/w microemulsion system. A mixture of benzyl alcohol and medium chain triglyceride (3/1) was chosen as the oil phase. Pseudoternary phase diagrams of the microemulsion formations were constructed in order to determine the optimum ratio of oils, the concentration range of surfactant and cosurfactant and the optimum ratio between them. Consequently, the suitability of the chosen microemulsion system as a parenteral formulation was evaluated using droplet size analysis and hemolysis tests. Among the surfactants and cosurfactants screened, a mixture of polyoxyethylene (50) hydrogenated castor oil and ethanol (3/1) showed the largest o/w microemulsion region in the phase diagram. The average droplet size of the microemulsions was < 150 nm, and the hemolysis test showed this formulation to be nontoxic to red blood cells. The pharmacokinetic profiles of the ITZ-microemulsion for itraconazole and its major metabolite, hydroxyitraconazole, were compared with those of a PEG 400 solution and cyclodextrin formulations in rats. Overall, these results highlight the potential of an ITZ-microemulsion formulation for the parenteral route.
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Affiliation(s)
- Yun-Seok Rhee
- College of Pharmacy, Sungkyunkwan University, Suwon 440-746, Korea
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46
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Girois SB, Chapuis F, Decullier E, Revol BGP. Adverse effects of antifungal therapies in invasive fungal infections: review and meta-analysis. Eur J Clin Microbiol Infect Dis 2006; 25:138-49. [PMID: 16622909 DOI: 10.1007/s10096-005-0080-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Amphotericin B is the main therapeutic agent for the treatment of invasive fungal infections; however, it is associated with significant toxicities that limit its use. Other systemic antifungal agents have been developed to improve tolerability while maintaining the efficacy profile of conventional amphotericin B. Fifty-four studies involving 9,228 patients were assessed for the frequency of adverse effects of the main systemic antifungal agents. While the results suggest that liposomal amphotericin B is the least nephrotoxic of the lipid formulations (14.6%), that conventional amphotericin B is the most nephrotoxic (33.2%), and that itraconazole is the most hepatotoxic (31.5%), the lack of standard definitions of antifungal-related adverse effects limits the validity of these results. Furthermore, heterogeneous patient pools and differing protocols make it difficult to draw direct comparisons between studies. With the advent of newer classes of systemic antifungal agents, future trials should conform to definitions that are universally applicable and clinically relevant to allow for such comparisons and to enable evidence-based decision-making.
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Affiliation(s)
- S B Girois
- Clinical Epidemiology Unit, Département d'Information Médicale des Hospices Civils de Lyon, France
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47
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Abstract
BACKGROUND Treatment of symptomatic sarcoidosis usually includes systemic immunosuppressive agents. These agents may render the patient more susceptible to opportunistic infections. In addition, the fungal infection may be difficult to distinguish from the underlying sarcoidosis. AIM To examine the presentation and management of invasive fungal infections in sarcoidosis patients. DESIGN Retrospective record review. METHODS We reviewed the notes of all sarcoidosis patients (n = 753) seen at our clinic over an 18-month period. RESULTS Seven patients (0.9%) with previously diagnosed sarcoidosis developed fungal infections: two each with Histoplasma capsulatum and Blastomyces dermatitidis and three others with Cryptococcus neoformans. No cases of invasive aspergillus or tuberculosis were identified. The diagnosis of fungal infection was made by bronchoscopy (four cases), open-lung biopsy (one case), bone-marrow aspirate (one case), and spinal fluid examination (one case). All patients were receiving corticosteroids at the time of worsening chest X-ray or clinical status. Four patients were also receiving methotrexate prior to infection. No patient with systemic fungal infection was receiving either infliximab or cyclophosphamide. All patients responded to anti-fungal therapy and a reduction in immunosuppression. DISCUSSION Fungal infections occur rarely in treated patients with sarcoidosis. Deterioration of chest X-ray, especially a localized infiltrate, warrants investigation.
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Affiliation(s)
- R P Baughman
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA.
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48
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Girois SB, Chapuis F, Decullier E, Revol BGP. Adverse effects of antifungal therapies in invasive fungal infections: review and meta-analysis. Eur J Clin Microbiol Infect Dis 2005; 24:119-30. [PMID: 15711785 DOI: 10.1007/s10096-005-1281-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Amphotericin B is the main therapeutic agent for the treatment of invasive fungal infections; however, it is associated with significant toxicities that limit its use. Other systemic antifungal agents have been developed to improve tolerability while maintaining the efficacy profile of conventional amphotericin B. Fifty-four studies involving 9,228 patients were assessed for the frequency of adverse effects of the main systemic antifungal agents. While the results suggest that liposomal amphotericin B (L-AmB) is the least nephrotoxic of the lipid formulations (14.6%), that conventional amphotericin B (AmB) is the most nephrotoxic (33.2%), and that itraconazole is the most hepatotoxic (31.5%), the lack of standard definitions of antifungal-related adverse effects limits the validity of these results. Furthermore, heterogeneous patient pools and differing protocols make it difficult to draw direct comparisons between studies. With the advent of newer classes of systemic antifungal agents, future trials should conform to definitions that are universally applicable and clinically relevant to allow for such comparisons and to enable evidence-based decision-making.
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Affiliation(s)
- S B Girois
- Clinical Epidemiology Unit, Département d'Information Médicale des Hospices Civils de Lyon, 162 Avenue Lacassagne, 69003 Lyon, France
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49
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Wark P. Pathogenesis of allergic bronchopulmonary aspergillosis and an evidence-based review of azoles in treatment. Respir Med 2004; 98:915-23. [PMID: 15481266 DOI: 10.1016/j.rmed.2004.07.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is a complex condition that affects people with asthma and cystic fibrosis (CF). It results from exposure to the fungus Aspergillus fumigatus, which leads to worsening airway inflammation and progressive damage to the lungs. The aim of this review is to outline the pathogenesis of the disorder, diagnostic criteria and to discuss the use of anti-fungal agents in its treatment. METHODS The Cochrane library of systematic reviews and the Cochrane database of controlled trials were searched for controlled trials on ABPA and its treatment in both asthma and CF. In addition, articles included within the reviews were examined separately, and a separate search carried out using Medline. RESULTS A systematic review for the use of azole anti-fungal agents in ABPA was identified for their use in both CF and non-CF-related disease. The review of ABPA alone identified two randomized-controlled trials of itraconazole in chronic disease. These trials demonstrated improvements in symptoms and immune activation, but were short-term trials and failed to show a significant change in lung function. No trials were identified in CF. CONCLUSIONS The use of anti-fungal agents in ABPA seems to be a rational one, with short-term efficacy demonstrated for the use of itraconazole. Further investigations are required to identify individuals who will benefit most from treatment and to establish the correct dose and means of delivering treatment in ABPA. Longer-term studies are required to demonstrate that treatment modifies the progressive decline in lung function seen with the disease.
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Affiliation(s)
- Peter Wark
- Brooke Laboratories, Southampton University, MP 810 Tremona Road, Southampton, UK.
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50
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Wiederhold NP, Lewis RE, Kontoyiannis DP. Invasive aspergillosis in patients with hematologic malignancies. Pharmacotherapy 2004; 23:1592-610. [PMID: 14695039 DOI: 10.1592/phco.23.15.1592.31965] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Invasive aspergillosis is an increasingly common and often fatal opportunistic fungal infection in patients with hematologic malignancies. Prolonged and profound neutropenia remains a key risk factor for the development of invasive aspergillosis. However, qualitative deficiencies in host immune responses resulting from prolonged corticosteroid therapy, graft-versus-host disease, and cytomegalovirus infection are important risk factors for the recurrence and progression of Aspergillus infections after bone marrow recovery. Early diagnosis of invasive aspergillosis remains a challenge, and few tools are available for monitoring its course once the diagnosis is established. Even with the recent introduction of new antifungal therapies, mortality in patients with invasive aspergillosis remains high, and uniformly effective prophylaxis or preemptive therapeutic strategies are lacking. Strategies such as combination antifungal therapy and immunotherapy often are used as first-line treatment approaches in patients with documented invasive aspergillosis despite a paucity of clinical trial data. Recent advances in our understanding of the epidemiology, pathogenesis, and treatment of invasive aspergillosis in patients with hematologic malignancies are reviewed. The problems and controversies associated with defining optimal treatment strategies for invasive aspergillosis in this heavily immunocompromised population are highlighted.
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