Relationships between prednisone therapy, disease activity, and the total serum IgE level in allergic bronchopulmonary aspergillosis

Airway mycosis in allergic airway disease

The allergic airway diseases, including chronic rhinosinusitis (CRS), asthma, allergic bronchopulmonary mycosis (ABPM) and many others, comprise a heterogeneous collection of inflammatory disorders affecting the upper and lower airways and lung parenchyma that represent the most common chronic diseases of humanity. In addition to their shared tissue tropism, the allergic airway diseases are characterized by a distinct pattern of inflammation involving the accumulation of eosinophils, type 2 macrophages, innate lymphoid cells type 2 (ILC2), IgE-secreting B cells, and T helper type 2 (Th2) cells in airway tissues, and the prominent production of type 2 cytokines including interleukin (IL-) 33, IL-4, IL-5, IL-13, and many others. These factors and related inflammatory molecules induce characteristic remodeling and other changes of the airways that include goblet cell metaplasia, enhanced mucus secretion, smooth muscle hypertrophy, tissue swelling and polyp formation that account for the major clinical manifestations of nasal obstruction, headache, hyposmia, cough, shortness of breath, chest pain, wheezing, and, in the most severe cases of lower airway disease, death due to respiratory failure or disseminated, systemic disease. The syndromic nature of the allergic airway diseases that now include many physiological variants or endotypes suggests that distinct endogenous or environmental factors underlie their expression. However, findings from different perspectives now collectively link these disorders to a single infectious source, the fungi, and a molecular pathogenesis that involves the local production of airway proteinases by these organisms. In this review, we discuss the evidence linking fungi and their proteinases to the surprisingly wide variety of chronic airway and systemic disorders and the immune pathogenesis of these conditions as they relate to environmental fungi. We further discuss the important implications these new findings have for the diagnosis and future therapy of these common conditions.

Allergic bronchopulmonary aspergillosis presenting as chronic cough in an elderly woman without previously documented asthma

A nonsmoking woman in her mid-70s presents to the allergist for consultation of a chronic cough of almost 3-years' duration without a specific diagnosis as to etiology in spite of numerous diagnostic tests and therapeutic trials. This is a case report from a specialist point of view that includes a comprehensive review of her clinical course pre- and postconsultation along with a brief but pertinent review of the literature as it relates to this particular unusual and protracted case, which was ultimately successfully diagnosed and treated.

Aspergillus-associated airway disease, inflammation, and the innate immune response

Aspergillus moulds exist ubiquitously as spores that are inhaled in large numbers daily. Whilst most are removed by anatomical barriers, disease may occur in certain circumstances. Depending on the underlying state of the human immune system, clinical consequences can ensue ranging from an excessive immune response during allergic bronchopulmonary aspergillosis to the formation of an aspergilloma in the immunocompetent state. The severest infections occur in those who are immunocompromised where invasive pulmonary aspergillosis results in high mortality rates. The diagnosis of Aspergillus-associated pulmonary disease is based on clinical, radiological, and immunological testing. An understanding of the innate and inflammatory consequences of exposure to Aspergillus species is critical in accounting for disease manifestations and preventing sequelae. The major components of the innate immune system involved in recognition and removal of the fungus include phagocytosis, antimicrobial peptide production, and recognition by pattern recognition receptors. The cytokine response is also critical facilitating cell-to-cell communication and promoting the initiation, maintenance, and resolution of the host response. In the following review, we discuss the above areas with a focus on the innate and inflammatory response to airway Aspergillus exposure and how these responses may be modulated for therapeutic benefit.

Voriconazole and posaconazole improve asthma severity in allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitization

Rationale and objectives. Severe asthma with fungal sensitization (SAFS) and allergic bronchopulmonary aspergillosis (ABPA) are progressive allergic fungal lung diseases whose effective treatment remains to be established. Current treatment with itraconazole is associated with a 40% failure rate and adverse events (AEs). We assessed the effect of voriconazole or posaconazole as second- and third-line therapies. Methods. We conducted a retrospective review of adult asthmatic patients with either ABPA or SAFS receiving voriconazole or posaconazole. Clinical, radiological, and immunological evaluation was used to assess response. Results. There were 25 patients, ABPA (n = 20) or SAFS (n = 5), 10 males, median age = 58 years. All patients had failed itraconazole (n = 14) or developed AEs (n = 11). There were 33 courses of therapy analyzed, 24 with voriconazole and 9 with posaconazole. Clinical response to voriconazole was observed in 17/24 (70%) patients at 3 months, 15/20 (75%) at 6 months, and 12/16 (75%) at 12 months compared with 7/9 (78%) at 3, 6, and 12 months for posaconazole. Eighteen of 24 (75%) patients discontinued oral corticosteroids (OCS), 12 of them within 3 months of therapy. Asthma severity was downgraded from severe to moderate (n = 8) and moderate to mild (n = 1) asthma in 9 of 24 (38%) asthmatic patients. There was a marked reduction in OCS and short-acting beta-2 agonist use, health-care utilization due to asthma, and improvement in overall health status. Furthermore, there was a statistically significant reduction in immunological markers appearing at 9 months (p = .008) for total IgE and at 12 months for radioallergosorbent test IgE for Aspergillus fumigatus (p = .0056). Six of 23 (26%) patients on voriconazole had AEs requiring discontinuation before 6 months compared with none on posaconazole (p = .15). Four relapsed (57%), one at 3 months and three at 12 months after discontinuation. Conclusion. Both voriconazole and posaconazole are potentially effective alternative treatment options for SAFS and ABPA and may improve asthma control and reduce severity, though larger prospective studies are required to support these retrospective study findings.

Role of inhaled corticosteroids in the management of serological allergic bronchopulmonary aspergillosis (ABPA)

BACKGROUND AND AIM

The treatment of choice for allergic bronchopulmonary aspergillosis (ABPA) is oral corticosteroids (OCS). However, they are associated with numerous adverse effects. Inhaled corticosteroids (ICS) are associated with fewer side-effects; however, their role in the management of ABPA remains controversial. In this retrospective study, we evaluate the role of high doses of ICS in serological ABPA (ABPA-S).

METHODS

Patients with ABPA-S were treated with a combination of formoterol/budesonide (24-1600 micrograms per day), and followed up with history, physical examination, chest radiograph and total IgE levels at 6, 12, 18 and 24 weeks. Asthma control was evaluated using the Global Initiative for Asthma (GINA) criteria. OCS were initiated if the IgE levels continued to rise after six months of therapy with ICS.

RESULTS

There were 8 men and 13 women with a mean (SD) age of 39.3 (12.9) years. There was subjective improvement in all patients treated with ICS but none had complete control of asthma. After six months of therapy with ICS, the median IgE levels increased by 99.3%. After the initiation of OCS, there was complete resolution of asthma symptoms in 19 patients, and IgE levels fell by a median of 52.6% at six weeks. The median duration of follow-up was 15 months after OCS therapy. Eighteen patients achieved complete remission and three patients had a relapse in the first three months after stopping OCS. One patient required long-term OCS and was classified as glucocorticoid-dependent ABPA.

CONCLUSION

High doses of ICS alone have no role in the management of ABPA-S and should not be used as first-line therapy. In patients receiving OCS or alternate therapy, ICS can be used as an add-on therapy for the control of symptoms of asthma.

Allergic bronchopulmonary aspergillosis

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

Clinical immunology review series: an approach to the use of the immunology laboratory in the diagnosis of clinical allergy

In the last 10 years UK immunology laboratories have seen a dramatic increase in the number and range of allergy tests performed. The reasons for this have been an increase in the incidence of immunoglobulin E (IgE)-mediated allergic disease set against a background of greater public awareness and more referrals for assessment. Laboratory testing forms an integral part of a comprehensive allergy service and physicians treating patients with allergic disease need to have an up-to-date knowledge of the range of tests available, their performance parameters and interpretation as well as the accreditation status of the laboratory to which tests are being sent. The aim of this review is to describe the role of the immunology laboratory in the assessment of patients with IgE-mediated allergic disease and provide an up-to-date summary of the tests currently available, their sensitivity, specificity, interpretation and areas of future development.

Specific serum immunopatterns in clinical phases of allergic bronchopulmonary aspergillosis

Immunoblotting, radioallergosorbent test (RAST), and enzyme-linked immunosorbent assay (ELISA) were performed to determine specific IgE and IgG responses to Aspergillus fumigatus (Af) allergens (IgE-Af; IgG-Af). Serology results were compared in patients with allergic bronchopulmonary aspergillosis (ABPA) (n = 43), patients with Aspergillus fumigatus-associated asthma (Af-asthma) (n = 26), and healthy individuals (n = 3). In patients with different clinical phases of ABPA, three specific immunopatterns were found by immunoblotting. It is proposed to classify ABPA into the active, intermediate, and remission phase with respect to the specific immunoresponse to Af-allergens and asthma symptoms. First, the active phase of ABPA is characterized by a fully developed specific immunoresponse to Af-allergens and severe asthma. Second, the intermediate phase includes patients with elevated specific immunologic findings without asthma symptoms. Third, the remission phase is characterized by a weak specific immunoresponse to Af-allergens after a long-term asymptomatic period. No correlation occurred between specific immunopatterns and irreversible brochopulmonary lesions. The IgE-Af RAST and IgG-Af ELISA titers of patients with ABPA in the active and intermediate phase were significantly higher compared with patients with ABPA in remission phase and with patients with Af-asthma. In particular, the demonstration of positive IgG-Af ELISA titer generally allows the serologic discrimination of patients with asthma and ABPA from patients with Af-asthma in clinical practice. The present study revealed that immunoblots of most patients with Af-asthma were negative. Immunoblotting demonstrated an IgG reactivity exclusively to low molecular weight (MW) Af-allergens in 8 out of 26 patients with Af-asthma and in the three healthy individuals, and this IgG response may reflect naturally occurring antibodies.

Controlled trial of natamycin in the treatment of allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis often requires treatment with oral corticosteroids to control the host response to Aspergillus fumigatus. In a double blind study 25 patients with allergic bronchopulmonary aspergillosis taking maintenance oral corticosteroids were randomly allocated to receive 5 mg natamycin or placebo by nebuliser twice daily for one year. The primary aim of the study was to assess the steroid sparing potential of natamycin. Standardised reductions in corticosteroid dosage were therefore undertaken every five weeks, unless clinically contraindicated. Five patients were withdrawn in the first four months: two (1 natamycin, 1 placebo) died, two (1 natamycin, 1 placebo) had suspected drug reactions, and one (natamycin) was non-compliant. The pretreatment characteristics of the 20 patients (10 in each group) who completed the study were similar, 17 (9 natamycin, 8 placebo) having evidence of recent disease activity. At the end of the study prednisolone dose had been reduced by a similar amount in each group (median natamycin 2.25 mg, placebo 2.5 mg). Evidence of disease activity during the study year (transient shadowing on the chest radiograph, blood eosinophilia, or increases in antibodies to A fumigatus, or any combination of these) was observed in similar numbers of patients in each group (5 natamycin, 7 placebo). There was no evidence that natamycin conferred benefit on these patients with allergic bronchopulmonary aspergillosis.

T- and B-cell dysregulation of IgE synthesis in cystic fibrosis patients with allergic bronchopulmonary aspergillosis

Since Aspergillus fumigatus (Af)-specific and polyclonal serum IgE levels are characteristically elevated in patients with allergic bronchopulmonary aspergillosis (ABPA), we evaluated in vitro regulation of IgE synthesis in cystic fibrosis (CF) patients with ABPA. We studied 11 CF patients with ABPA, 37 patients with positive Af prick skin tests and/or IgG precipitating antibodies (ST/PPT+), and 35 patients with no humoral or skin responses to Aspergillus (ST/PPT-). Mean serum IgE concentration was significantly elevated in CF subjects with ABPA compared to ST/PPT+ and ST/PPT- patients, 2866 vs 303 and 61 IU/ml, respectively (P less than 0.01). In vitro studies demonstrated that ABPA patients' B cells spontaneously synthesized significantly increased amounts of IgE compared to ST/PPT positive and negative subjects, 1980 vs 220 and 13 pg/ml, respectively (P less than 0.01). In addition, preformed B-cell-associated IgE was also significantly elevated in ABPA subjects (P less than 0.01), indicating prior in vivo activation. Supernatant cultures of Af-stimulated T cells from ABPA subjects significantly induced allogeneic B-cell IgE synthesis compared to ST/PPT positive and negative CF subjects, 206 vs 13 and 4 pg/ml, respectively (P less than 0.01). Thus T cells stimulated with Aspergillus antigens secrete cytokines that induce B-cell IgE synthesis in ABPA subjects. B-cell IgE hyperactivity is manifested by in vivo and in vitro increased IgE concentrations. Analyses of T-cell regulation and B-cell IgE synthesis distinguish CF subjects with ABPA from Aspergillus sensitive non-ABPA subjects.

Allergic bronchopulmonary aspergillosis in corticosteroid-dependent asthmatics

Forty-two corticosteroid-dependent asthmatics were studied to determine whether their underlying disease might be allergic bronchopulmonary aspergillosis (ABPA). The clinical and laboratory characteristics studied included age, sex, atopic status, mean corticosteroid doses, skin tests to Aspergillus fumigatus (Af), precipitins to Af, total serum IgE, and chest roentgenograms. Twelve patients had four or more of the seven primary criteria used and were considered as the ABPA suspect group. Further studies identified three patients who were considered to have definite ABPA and an additional three patients with probable ABPA. This study suggests that previously undiagnosed ABPA can be detected in populations of corticosteroid dependent asthmatics. Corticosteroid therapy may mask ABPA, and serial evaluations of these patients may be of value in detecting additional cases of the disease.

A guide to the recent literature on aspergillosis as caused by Aspergillus fumigatus, a fungus frequently found in self-heating organic matter

Spores of Aspergillus fumigatus have been found to be abundantly present in the outdoor air at a site where large scale experimental composting of sewage sludge is in progress at Beltsville, Maryland. The health significance of this finding, for that site and for others in the future, is still only incompletely understood. Further studies are in progress to characterize absolute concentrations of the spores of the fungus in air at the site, spore dispersal by air from composting operations, and background environmental spore levels in air. The present paper contains a list of references to papers on health effects of A. fumigatus, many published in the past ten years, along with a review of the same designed to assist the reader in finding information on particular aspects of the subject in the literature. It is intended primarily as an aid to individuals interested in sludge composting and wishing to attain an insight into the A. fumigatus-composting situation, but it may also interest others concerned with other substrates which become moldy at 40--50 C. A. fumigatus has been found in great numbers in naturally and artificially heated environments such as decaying leaves, compost heaps, solar heated sloughs, cooling canals for nuclear power generators, silos, grain storage bins, boiler rooms, detritus around steam turbines and sauna baths. The evident practical merits of sludge composting have been described elsewhere; the information presented here has its main significance in respect to requirements for choice of locations for composting sites and to process and design criteria.

Incidence of immediate sensitivity to Aspergillus fumigatus in a North American asthmatic population

Allergic bronchopulmonary aspergillosis might be less frequent in North America because the incidence of immediate sensitivity by asthmatics to A. fumigatus is less. In order to check this hypothesis, 200 asthmatics were skin tested with two extracts of A. fumigatus which had been shown to produce positive reactions in fifty patients who had allergic aspergillosis. Of the asthmatics, 21.5% reacted to the commercial extract by prick testing and 39% by intradermal testing. Using an extract kindly provided by Professor Pepys, 19.5% reacted to a concentration of 1 mg/ml and 31.5% to 10 mg/ml. By the prick method, 21.5% reacted to both extracts. Specific IgE was measured with one of the extracts and a good correlation (r = 0.48) was found with the size of the prick reaction. The increase in specific IgE was reflected in the increase of total IgE (r = 0.84). The authors conclude that the incidence of immediate sensitivity to A. fumigatus in asthmatic patients in North America is at least equal to that found in the U.K.