The Temporal Sequence of the Transition from Asthma through Allergic Bronchopulmonary Aspergillosis to Chronic Pulmonary Aspergillosis

Ref ID: 19578

Author:

D Lowes1,2*, L Chishimba1,2, DW Denning1,2

Author address:

1National Aspergillosis Centre, University Hospital of South Manchester, UK
2University of Manchester, Manchester, UK

Full conference title:

6th Advances Against Aspergillosis 2014

Abstract:

Introduction:
Allergic bronchopulmonary aspergillosis (ABPA) is an uncommon complication of asthma, occurring
in 0.7-4.1% of cases in secondary care. There are an estimated 4,800,000 cases of ABPA worldwide.
Development of chronic pulmonary aspergillosis (CPA) in patients with ABPA is a well-recognised
but poorly understood phenomena. Whilst oral itraconzole is frequently used in the management of
patients with ABPA, voriconazole and posaconazole is often used in those who develop CPA. The
temporal sequence of the transition from asthma through ABPA to CPA is not well described.
Method:
Patients with problematic CPA in the UK are cared for at one national centre, the National
Aspergillosis Centre (NAC), based at the University Hospital of South Manchester. These patients
are screened for a dual diagnosis of ABPA and CPA. In cases referred to the NAC prior to 1st of
June 2012 in whom a dual diagnosis was suspected, the full medical records were reviewed and
discussed by a multi-disciplinary team to make judgements on the likely onset of asthma, ABPA and
CPA. ABPA was defined as the highest serum total IgE of greater than 1000 IU/L, or raised serum
anti-Aspergillus IgE (or positive Aspergillus skin prick test), a history of asthma, with compatible
symptoms of ABPA. CPA was defined as positive Aspergillus precipitins, or highest serum anti-
Aspergillus IgG of >40 mg/L with radiological findings consistent with CPA (Nodule disease, lobar
shrinkage and fibrosis, pleural capping, and cavity formation with or without fungal balls).
Results:
Of all patients referred to the NAC prior to 1st of June 2012 (392 patients), 42 were recorded as
having a co-existing diagnosis of asthma, ABPA and CPA. On review of the medical records, 20 were
considered to have a clear progression from asthma, through ABPA to CPA. Seven patients did not
have CPA, five patients did not to have ABPA but a Th-2 response to chronic pulmonary aspergillosis,
with a high total IgE. Six patients were considered to have developed CPA due to causes other than
ABPA. The remaining four patients had too much missing data in the medical records to allow
timing and diagnostic judgements to be made. Of the 20 patients included, twelve were female and
8 were male. Figure 1 shows the ages at which the 20 patients developed asthma, ABPA and CPA,
including long-term asthma remissions. Patients one to 15 developed chronic cavitary pulmonary
aspergillosis, patients 16 and 17 developed Aspergillus nodule disease, and patients 18, 19 and 20
all developed the radiological appearance of CPA but remained anti-Aspergillus IgG negative.The
patient documented on line 2 is case 44 in the case histories from www.aspergillus.org.uk.
Discussion:
The overlapping criteria for the diagnosis of CPA and ABPA make the diagnosis of CPA in patients
with ABPA challenging. There is considerable range in the length of time the patients in this series
had asthma and ABPA prior to the onset of CPA. A clearer definition of CPA in ABPA is needed to
guide diagnosis and criteria for escalation in antifungal therapy.

Figure 1: The age at which patients developed asthma (and long-term asthma remissions), allergic
bronchopulmonary aspergillosis and chronic pulmonary aspergillosis.

Abstract Number: 103

Conference Year: 2014

Link to conference website: http://www.AAA2014.org

New link: NULL

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