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CME

Allergic Bronchopulmonary Aspergillosis

General Information

Description

  • allergic pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus and rarely other Aspergillus species, characterized by chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis1,2,5
  • occurs almost exclusively in patients with cystic fibrosis (CF) or asthma1,2,5

Also called

  • ABPA

Definitions

  • Aspergillus-associated respiratory disorders1
    • affecting lower respiratory tract
      • allergic aspergillosis, including
        • allergic bronchopulmonary aspergillosis (ABPA)
        • immunoglobulin E (IgE)-mediated Aspergillosis-induced asthma (AIA)
        • hypersensitivity pneumonitis
      • saprophytic colonization - simple and complex aspergilloma
      • invasive disease - acute and subacute invasive aspergillosis
    • affecting upper respiratory tract
      • allergic aspergillosis (allergic Aspergillosis sinusitis [AAS])
      • saprophytic colonization (sinus fungal balls)
      • invasive disease, including
        • acute fulminant invasive sinusitis
        • chronic invasive sinusitis
        • granulomatous invasive sinusitis

Types

  • stages are classification system and do not reflect sequential disease progression but may help guide treatment1,2,5
  • stages of allergic bronchopulmonary aspergillosis (ABPA)1,2,5
    • stage I (acute) - new, active acute disease
    • stage II (remission) - clinical, radiologic, and serologic remission for ≥ 6 months (asymptomatic)
    • stage III (recurrent exacerbations) - recurrent exacerbation or relapse, defined as
      • development of new infiltrates
      • ≥ 100% increase in total serum immunoglobulin E (IgE) level
    • stage IV (corticosteroid-dependent) - chronic corticosteroid-dependent asthma secondary to ABPA
    • stage V (fibrotic lung disease) - end-stage fibrosis and cavitation secondary to progressive airway inflammation and dilation
  • International Society for Human and Animal Mycology (ISHAM) working group proposed clinical staging1
    • stage 0 - clinically stable and well-controlled asthma without signs/symptoms suggestive of ABPA but with ABPA diagnosis
    • stage 1 (acute) - based on computed tomography and/or bronchoscopic findings
      • 1a - with mucoid impaction
      • 1b - without mucoid impaction
    • stage 2 (response) - clinical and radiological improvement with reduced serum IgE level ≥ 25% after 8 weeks of therapy
    • stage 3 (exacerbation) - any clinical and/or radiological worsening plus increased serum IgE level > 50% of baseline
    • stage 4 (remission) - sustained clinical and radiological improvement plus baseline serum IgE levels (or < 50% increase) for > 6 months without systemic corticosteroids
    • stage 5a (treatment-dependent ABPA)
      • > 2 consecutive relapses within 6 months of stopping treatment
      • worsening of clinical, radiological, or immunological parameters on tapering
    • stage 5b (glucocorticoid-dependent ABPA) - systemic corticosteroids required for asthma control when ABPA is controlled
    • stage 6 (advanced ABPA) - clinical signs of cor pulmonale and type-2 respiratory failure plus radiological evidence of fibrosis
  • further radiologic disease classification1,2
    • ABPA - serologic (ABPA-S, considered precursor to ABPA-CB)
    • ABPA - central bronchiectasis (ABPA-CB)
    • ABPA - high-attenuation mucous (HAM) plugs (ABPA-HAM)
    • ABPA - chronic pleuropulmonary fibrosis (ABPA-CPF)

References

General references used

  1. Shah A, Panjabi C. Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity. Allergy Asthma Immunol Res. 2016 Jul;8(4):282-97full-text
  2. Greenberger PA, Bush RK, Demain JG, Luong A, Slavin RG, Knutsen AP. Allergic bronchopulmonary aspergillosis. J Allergy Clin Immunol Pract. 2014 Nov-Dec;2(6):703-8full-text
  3. Stevens DA, Moss RB, Kurup VP, et al. Allergic bronchopulmonary aspergillosis in cystic fibrosis-state of the art: Cystic Fibrosis Foundation Consensus Conference. Clin Infect Dis. 2003 Oct 1;37 Suppl 3:S225-64full-text, correction can be found in Clin Infect Dis. 2004 Jan 1;38(1):158
  4. Limper AH, Knox KS, Sarosi GA, et al; American Thoracic Society Fungal Working Group. An official American Thoracic Society statement: Treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128
  5. Bains SN, Judson MA. Allergic bronchopulmonary aspergillosis. Clin Chest Med. 2012 Jun;33(2):265-81

Recommendation grading systems used

  • Cystic Fibrosis Foundation (CFF) grading system
    • grade of evidence
      • Grade I - evidence obtained from ≥ 1 properly randomized controlled trial (RCT)
      • Grade II-1 - evidence obtained from well-designed controlled trials without randomization
      • Grade II-2 - evidence obtained from well-designed cohort or case-control analytic studies, preferably from > 1 center or research group
      • Grade II-3 - evidence obtained from multiple time series with or without intervention; dramatic results in uncontrolled experiments
      • Grade III - opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committee
    • Reference - CFF guideline on allergic bronchopulmonary aspergillosis in cystic fibrosis (Clin Infect Dis 2003 Oct 1;37 Suppl 3:S225full-text), correction can be found in Clin Infect Dis. 2004 Jan 1;38(1):158
  • European Respiratory Society/American Thoracic Society (ERS/ATS) grading system
    • strength of recommendation
      • Strong - most individuals should receive intervention; adherence to recommendation according to guideline could be used as quality criterion or performance indicator
      • Conditional - different choices will be appropriate for individual patients; help each patient arrive at management decision consistent with his or her values and preferences
    • levels of evidence
      • High - further research is very unlikely to change our confidence in the estimate of effect
      • Moderate - further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
      • Low - further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
      • Very low - any estimate of effect is very uncertain
    • Reference - ERS/ATS guideline on definition, evaluation, and treatment of severe asthma (24337046Eur Respir J 2014 Feb;43(2):343full-text)
  • American Thoracic Society (ATS) grading system for recommendations
    • strength of recommendations
      • Category A - good evidence to support a recommendation for use
      • Category B - moderate evidence to support a recommendation for use
      • Category C - poor evidence to support a recommendation for or against use
      • Category D - moderate evidence to support a recommendation against use
      • Category E - good evidence to support a recommendation against use
    • grades of evidence
      • Grade I - evidence from at least 1 properly randomized controlled trial
      • Grade II - evidence from at least 1 well-designed clinical trial without randomization, from cohort and case-controlled analytical studies (preferably from > 1 center), from multiple patient series studies, or from dramatic results of uncontrolled experiments
      • Grade III - evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
    • Reference - ATS guideline on treatment of fungal infections in adult pulmonary and critical care patients (21193785Am J Respir Crit Care Med 2011 Jan 1;183(1):96)

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National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T115466, Allergic Bronchopulmonary Aspergillosis; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T115466. Registration and login required.

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