Allergic Bronchopulmonary Aspergillosis (ABPA)

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology

Pulmonary Infiltrates with Eosinophilia (PIE) Syndromes are a heterogeneous group of lung diseases.


Pulmonary Infiltrates with Eosinophilia (PIE) (click to enlarge the image).


Allergic Bronchopulmonary Aspergillosis (ABPA)

There remains a lack of agreement on diagnostic criteria and approaches to treatment of patients with allergic bronchopulmonary aspergillosis (ABPA). http://buff.ly/1zJUpyk

ABPA occurs in patients with severe asthma who are often steroid-dependent. It occurs in 10% of patients with cystic fibrosis according to some studies ABPA is caused by the spores of Aspergillus fumigatus and is characterized by peripheral eosinophilia and high IgE (greater than 1,000 ng/mL (417 IU/ml)). ABPA is due to fungal colonization, not to local invasion.

T cell predominance in lung diseases:

CD8: hypersensitivity pneumonitis (HP) and COPD

Th2, CD4: Asthma, ABPA, pulmonary eosinophilia

Th1, CD4: granulomatous TB, sarcoid, berylliosis

Allergic Bronchopulmonary Aspergillosis (ABPA) (click to enlarge the image).

ABPA occurs in 1-2% of patients with asthma and 1-15% of patients with cystic fibrosis (CF).

Untreated ABPA rapidly progresses to severe central bronchiectasis and pulmonary fibrosis.

A
ABPA
Asthma
Aspergillus

Diagnosis of ABPA

Essential diagnostic criteria for ABPA:

- asthma
- high IgE (greater than 1,000 ng/mL (417 IU/ml))
- immediate skin test reactivity to A. fumigatus (skin prick test)
- elevated specific IgE to A. fumigatus
- chest CT with central bronchiectasis

ABPA stages

Untreated ABPA evolves through 5 stages:

1. acute phase
2. remission
3. exacerbation
4. steroid-dependent asthma
5. pulmonary fibrosis

ABPA treatment

ABPA treatment is with oral corticosteroids (CS) long term. The typical dose is daily prednisone at 0.5-1 mg/kg until there is a clinical improvement and a resolution of infiltrates on CXR.

The antifungal medication itraconazole can be also be helpful.

The treatment goal is to prevent the development or progression of bronchiectasis and worsening of pulmonary function.

Monitoring of ABPA therapy

Rising IgE levels can predict an ABPA recurrence. Doubling of the baseline IgE often indicates an ABPA exacerbation.

References

Allergy and Immunology MKSAP, 3rd edition.
More Than Asthma: Allergic Bronchopulmonary Aspergillosis. NEJM Images in Clinical Medicine, 08/2008.
Allergic Bronchopulmonary Aspergillosis: Challenges in Diagnosis. Viswanath P. Kurup, PhD, Banani Banerjee, PhD, Paul A. Greenberger, MD, and Jordan N. Fink, MD. Medscape General Medicine, 12/23/1999.
Allergic Bronchopulmonary Aspergillosis. MK Cheezum, CJ Lettieri. Medscape Allergy & Clinical Immunology, 2008.
Allergic Bronchopulmonary Aspergillosis (ABPA). Russell Blair, MD; Jeremy S. Breit, MD; Stephen P. Peters, MD, PhD. Merck Manual, 2008
Allergic Bronchopulmonary Aspergillosis. Ritesh Agarwal. CHEST March 2009 vol. 135 no. 3 805-826.
Aspergillosis. NEJM, 04/2009.

Published: 02/08/2008
Updated: 08/22/2010