Pulmonary allergic aspergillosis

Liposomal Amphotericin B Fosters the Corticosteroids' Anti-inflammatory Effect on Murine Allergic Bronchopulmonary Aspergillosis Model Airways

Fungus is an antigen for bronchial asthma causing allergic bronchopulmonary mycosis (ABPM). As a therapy other than corticosteroids, itraconazole (ITCZ) is known to suppress the allergic inflammation induced by Aspergillus fumigatus (Af). However, the efficacy of liposomal amphotericin B (LAMB) with/without corticosteroid on ABPM is unknown. Mice sensitized to Dermatophagoides farinae (Df) allergen were intranasally infected with Af (DfAf group). After the infection, corticosteroid (dexamethasone (Dex)) was administered for 5 days (DfAf/Dex group). The effects of ITCZ or LAMB with/without Dex were also evaluated. Pathologically, Dex and LAMB combination treatment decreased the allergic inflammation evidently. The bronchoalveolar lavage fluid (BALF) concentrations of IL-5, IL-13, and MIP-2 were significantly elevated in DfAf mice compared with control mice (p < 0.05, each). In DfAf mice, ITCZ and LAMB significantly decreased the elevation of MIP-2 (p < 0.05 vs the DfAf group). The addition of both Dex and LAMB suppressed the MIP-2 elevation in DfAf mice (p < 0.05 vs the Df/Af/Dex/LAMB group), but the addition of Dex and ITCZ did not (DfAf/Dex/ITCZ group). None of Dex, ITCZ, or LAMB decreased pulmonary IL-13 concentration. It was suggested that combination of antifungal drugs and corticosteroid enhanced the suppressing effect of airway inflammations. This finding will give a hope for the treatment of severe fungus-related asthma.

Mild, moderate, and severe forms of allergic bronchopulmonary aspergillosis: a clinical and serologic evaluation

BACKGROUND

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disorder induced by Aspergillus species colonizing the bronchial tree. There are patients with asthma who fulfill the diagnostic criteria of ABPA by serologic evaluation (specific IgE/IgG to Aspergillus fumigatus), bronchography, CT, and or conventional linear tomography.

OBJECTIVE

To identify different forms of ABPA based on various diagnostic criteria.

METHODS

Eighteen patients with asthma fulfilling the criteria of ABPA were evaluated in the present study. Six patients each received a diagnosis of ABPA serologic positive (ABPA-S), ABPA with central bronchiectasis (ABPA-CB), and ABPA with central bronchiectasis and other radiologic features (ABPA-CB-ORF).

RESULTS

The spirometric changes in the ABPA-S group (group 1) were mild, in the ABPA-CB group (group 2) were moderate, and in the ABPA-CB-ORF group (group 3) were severe. Absolute eosinophil count was raised in each group but was maximum (1,233 micro L) in severe form of disease (group 3). Specific IgE against A fumigatus was raised in each group, and the maximum was 47.91 IU/mL in ABPA-CB-ORF. CT scan findings of the ABPA-S group were normal without central bronchiectasis. The exacerbation in symptoms was maximum in group 3 compared to other groups.

CONCLUSION

The present observations suggest that ABPA includes mild (ABPA-S), moderate (ABPA-CB), and severe (ABPA-CB-ORF) forms of disease. It is recommended, therefore, that the disease should be diagnosed early, treated at the mild form of disease (ABPA-S), and prevented from leading to ABPA-CB or ABPA-CB-ORF.

Recurrence of allergic bronchopulmonary aspergillosis in the posttransplant lungs of a cystic fibrosis patient

Cystic fibrosis (CF) is an autosomal recessive disease of exocrine origin. Allergic bronchopulmonary aspergillosis (ABPA) is an immunologic disorder caused by colonization of the airways with Aspergillus fumigatus. A fumigatus has been cultured from posttransplant lungs in CF patients. Colonization of posttransplant lung with Aspergillus is a recognized phenomenon. In this case report, however, we present a patient who developed ABPA both before and after lung transplant. This patient meets the criteria for ABPA based on serologic results. ABPA may be a complication in post-CF lung transplant patients and serologic analysis should be considered when eosinophilia and pulmonary infiltrates or decline in lung function occurs.

Pulmonary mycosis in farmed deer: allergic zygomycosis and invasive aspergillosis

During 1988, pulmonary mycosis was diagnosed in four of 116 farmed deer examined on suspicion of tuberculosis. The histopathology showed allergic bronchopulmonary mycosis in a red deer (Cervus elaphus) and the agent was identified as a zygomycete, probably Absidia corymbifera, by immunofluorescence staining. Three fallow deer (Dama dama) had invasive necrotizing mycotic pneumonia and progressive exudative mycotic alveolitis caused by Aspergillus fumigatus. In the red deer, weakness due to paratuberculosis had probably promoted the mycotic infection. The three fallow deer were bred on another farm, where predisposing factors included mouldy straw and incorrect management.

A pathologic study of allergic bronchopulmonary aspergillosis

A lung biopsy specimen was obtained from a 10-year-old boy with cystic fibrosis and allergic bronchopulmonary aspergillosis. Light microscopy revealed a marked inflammatory process that was largely bronchocentric. Infiltrating cells included lymphocytes, plasma cells, monocytes, and numerous eosinophils. Elastin layers were intact in blood vessels and markedly disrupted in bronchioles. By immunofluorescent, major basic protein was demonstrated in eosinophils, was freely deposited outside of eosinophils, especially in the interlobular septum, and was taken up by macrophages. A number of lymphocytes stained positively for IgE. Through an immunoperoxidase stain, septate hyphae of Aspergillus were clearly observed in the lung parenchyma. A significant increase in interleukin-2 positive-staining T cells was observed with an approximate 2:1 ratio of helper to suppressor cells. The use of newer immunohistologic techniques has enabled us to gain additional insights into the pathogenesis of allergic bronchopulmonary aspergillosis.

Pathogenetic and serological aspects of pulmonary aspergillosis

Af is an important pathogen of the bronchopulmonary system, and the clinical spectrum encompasses aspergilloma, CNPA, IPA, ABPA, bronchial asthma, and allergic alveolitis. Bronchial carriage may, however, not always be associated with pathological effects. The polymorphism of the aspergillus-related disorders seems mostly to depend upon the different responses of the hosts. This review considers the antigenic composition of Af and specific antibody responses in man in relation to the pathogenesis and diagnosis of the various forms of pulmonary aspergillosis. More than 200 macromolecular components have been listed for Af and more than 30 antigens found to react with human sera. Serum antibodies to Af are common in healthy subjects. Schønheyder and his associates (A-L) have shown that IgG, IgA and IgM antibodies in healthy subjects are directed towards antigens to which also patients with aspergillosis strongly react. With immunofluorescent staining these antigens were found to be associated with hyphal walls, and a MW 470,000 fraction from ruptured mycelium was most reactive in ELISA. The respiratory tract appears to be the major route for exposure since the humoral responses include IgA class antibodies, and sIgA antibodies are found in bronchial secretions. Moreover, IgG antibody levels to the MW 470,000 fraction correlate with occupational exposure and smoking habits. In patients with cystic fibrosis high IgG antibody levels to MW 470,000 and MW 25,000-50,000 antigen fractions were associated with the carriage of Af in the sputum. An individual patient's level of IgA antibodies to the MW 470,000 fraction was inversely related to the Af carrier rate, and this was also true for IgE dependent reactivity to Af antigens. These observations indicate that IgG antibodies to some antigens mirror the extent of antigenic exposure, whereas some IgA and IgE antibodies may play a protective role against bronchial colonization with Af. IgG antibody determinations by ELISA were found to provide a higher diagnostic efficacy in pulmonary aspergillosis than IgA antibody assays. With IgG antibodies there were statistically significant differences between patients and the controls and there was little overlap of ELISA values between the groups. The fractions of MW 250,000 with catalase activity and MW 25,000-50,000 with protease activity, were most suitable for serological diagnosis. A gel immunoelectrophoretic assay proved Af catalase to be a major diagnostic antigen in patients with aspergilloma or with an apical aspergillus lung infiltrate.(ABSTRACT TRUNCATED AT 400 WORDS)

Aspergillus osteomyelitis. Report of a case and review of the literature

Aspergillus is a ubiquitous saprophytic fungus seldom pathogenic for normal hosts. Aspergillus osteomyelitis occurs infrequently and is typically limited to patients with predisposing factors, including leukocyte dysfunction, malignancy with neutropenia, steroid or antibiotic therapy, pulmonary aspergillosis, and surgical manipulation. The spine is most frequently affected, and the clinical presentation is nonspecific (50% afebrile). Diagnosis requires demonstration of characteristic, acutely branching, broad, septate hyphae in biopsy material, and culture of Aspergillus. Therapy includes debridement of necrotic bone and loculated purulence combined with amphotericin B and possibly 5-fluorocytosine or rifampin.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) occurs as a complication of asthma. It presents as an infiltrative pulmonary disorder with respiratory and systemic symptoms, eosinophilia, elevated total serum IgE, and skin sensitizing, as well as precipitating antibodies to Aspergillus fumigatus. Sputum cultures are not always positive for the organism. If unchecked, the disease may lead to bronchiectasis and ultimately pulmonary fibrosis. Therapy consists mainly of corticosteroids.

Immunologic mechanisms in pulmonary disease

This article reviews some concepts about the organization of the immune system and the immunopathologic mechanisms of hypersensitivity. This is followed by a discussion of the effect of excessive or inappropriate immunologic resources on the respiratory tract.

HLA antigen frequencies in allergic bronchopulmonary aspergillosis

The frequency of HLA antigens in twenty-two Caucasian patients with allergic broncho-pulmonary aspergillosis (ABPA) and sixty-nine unrelated Caucasian controls was determined. The results indicated that there was no increased frequency of a specific HLA antigen in patients with ABPA. Moreover, studies in thirteen families of ABPA patients also demonstrated that, within families, there was no consistent association between a specific haplotype and asthma, allergies or hay fever.

Immunologic responses to therapy in allergic bronchopulmonary aspergillosis: serum IgE value as an indicator and predictor of disease activity

Two patients, a child and an adult, with allergic bronchopulmonary aspergillosis were studied over an 18-month period. Initially elevated total serum IgE levels fell during prednisone therapy and rose prior to and during an exacerbation. Total serum IgG fell with therapy, whereas the values of IgA and IgM remained constant. Specific IgG and IgE values against Aspergillus fumigatus as measured by radioimmunoassay were elevated in both patients. Specific IgE values increased in each patient prior to exacerbation, whereas specific IgG values increased in only one patient at the time of exacerbation. Immunologic evaluation may provide an assessment of disease activity of prospective value.

Allergic bronchopulmonary aspergillosis in three patients with normal chest x-ray films

Three patients with allergic bronchopulmonary aspergillosis had normal chest x-ray films at the time of dianosis. None had a history of pneumonitis or abnormal chest x-ray films in the past. On the basis of clinical and immunologic data that indicated the presence of allergic bronchopulmonary aspergillosis, bronchograms were obtained, which revealed evidence of proximal bronchiectasis in each patient. These early changes in bronchial architecture were not evident on the plain x-ray films of the chest but were revealed by bronchographic study. The diagnosis of allergic bronchopulmonary aspergillosis may be made even in the presence of normal chest x-ray films.

Studies in chronic allergic bronchopulmonary aspergillosis. 1. Clinical and physiological findings

This report outlines the clinical and physiological features in 50 asthmatic patients with chronic allergic bronchopulmonary aspergillosis in whom the diagnosis was made from 2 to 25 years ago (mean duration 10-9 years). From a questionnaire and analysis of the peak expiratory flow rate measurements it was found that they were worse in the winter months, corresponding to the maximal concentrations of Aspergillus fumigatus in the atmosphere. Nineteen patients reported daily sputum production of up to an eggcupful or more, and 24 had noticed sputum 'plugs' in the previous year. Reduction of vital capacity (VC) was found in 20 patients, of forced expiratory volume in one second (FEV1) in 38 patients, and of maximal expiratory flow at 50% VC breathing air (V50air) in 47 patients. Nine patients had significantly reduced gas transfer factor (DLCO). Significant improvement (more than 15%) in FEV1 after inhaled bronchodilator was shown by only 17 patients. There were statistically significant correlations between the degree of reduction in the physiological measurements of VC, FEV1, and V50air with the age of the patient at the time of the study and the later in life the diagnosis of aspergillosis was made, whereas the reduction in DLCO was also significantly related to the duration of aspergillosis. Prospective studies are needed for a proper assessment of any protective effect of treatment on the pathophysiological changes due to the disease over many years.

Treatment of allergic aspergillosis with triamcinolone acetonide aerosol

The successful management of a patient with allergic asperillosis with triamcinolone acetonide for one year is reported. This patient had been maintained previously on systemic attempt to withdraw systemic corticosteroids continuously for eight years. An initial attempt to withdraw systemic steroids after initiation of aerosol therapy was unsuccessful; however, following bronchoscopic removal of mucus plugs, the transfer to maintenance therapy with triamcinolone aerosol alone was uneventful.

Pulmonary hypersensitivity to Alternaria and Aspergillus in baker's asthma

In two cases of baker's asthma pulmonary hypersensitivity was found to the fungi Alternaria and Aspergillus. Provocative bronchial challenge revealed a dual response; an immediate and an Arthus type hypersensitivity to Aspergillus in the first case. A primary binding assay revealed high titres of anti-Aspergillus antibody in the serum. In the second case intradermal and bronchial challenge suggested an immediate type I hypersensitivity response to Alternaria. The suspected organisms were present in the room air of the bakeries. It is suggested that an immunological response to these airborne fungi may have contributed to the pathogenesis of baker's asthma.

Asthmatic pulmonary eosinophilia: a review of 65 cases

In a series of 65 patients with asthma with pulmonary eosinophilia 54 were adequately investigated for allergic aspergillosis and this was present in 32 (59%). Asthma with pulmonary eosinophilia was found to carry a relatively poor prognosis in terms of permanent symptoms, impairment of pulmonary function and residual radiographic abnormality. The prognosis was least favourable when allergic aspergillosis was associated with long-standing asthma. On the other hand there was a group of patients with asthma with pulmonary eosinophilia who had relatively little permanent disability. These were mainly women with asthma of recent onset, and in these evidence of allergy to Aspergillus fumigatus was less apparent. Those patients who received long-term daily corticosteroid therapy were less likely to develop further radiographic opacities than those given intermittent corticosteroid therapy. To prevent recurrent pulmonary infiltrates it is probably necessary to give prednisolone in a daily dosage of at least 10 mg for an indefinite period.

Hyperimmunoglobulinemia E in a child with allergic bronchopulmonary aspergillosis and bronchiectasis

A 12-year-old boy was hospitalized for resection of a bronchiectatic lesion. Investigation of an elevated cencentration of serum IgE led to a diagnosis of allergic bronchopulmonary aspergillosis. ABPA has rarely been described in the pediatric age group. This hypersensitivity lung disease is characterized by intermittent wheezing, fever, recurrent pulmonary infiltrates, eosinophilia, hyperimmunoglobulinemia E, and Type I (allergic) skin reactivity to aspergillus extract. Hyphae of aspergillus may also be found in expectorated brown mucus plugs. Type III (Arthus) skin test response and presence of precipitating antibody to this fungus may be demonstrated. Central bronchiectasis or pulmonary fibrosis may result from uncontrolled progression of this disease.

Allergic bronchopulmonary aspergillosis: an increasing clinical problem

Allergic bronchopulmonary aspergillosis is being recognized with increasing frequency in the United States. The characteristics of the disease are recurrent pyrexia, cough, wheezing, sputum plugs containing aspergilli, fleeting pulmonary infiltrates, eosinophilia, dual skin reactions (immediate and late), and antibodies to the fungus in the blood. The pathogenetic mechanism is believed to involve type I and type III hypersensitivity reactions. Adrenal corticosteroids are effective in treating this condition.