Allergic bronchopulmonary aspergillosis - Symptoms, diagnosis and treatment | BMJ Best Practice

Last reviewed:November 2019

Last updated:May 2018

Summary

Hypersensitivity reaction to Aspergillus fumigatus mould that has colonised bronchi of patients with asthma or cystic fibrosis.

Exposure of atopic people to fungal spore elements results in the formation of IgE and IgG antibodies.

Presents as asthma complicated by bronchial obstruction, fever, malaise, expectoration of brownish mucus plugs, peripheral blood eosinophilia, and haemoptysis.

Treatment involves environmental control measures, corticosteroids, and itraconazole.

Early detection and treatment can prevent the development of bronchiectasis or pulmonary fibrosis that otherwise occurs in the later stages of the disease.

Definition

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to mould that occurs when bronchi become colonised by Aspergillus fumigatus in an otherwise immunocompetent person.[1][2] Patients usually have a prior diagnosis of atopy, asthma, or cystic fibrosis.[3] Exposure of an atopic person to fungal elements results in the formation of IgE and IgG antibodies.[4] Typically, the patient presents with bronchial obstruction, airway inflammation, and mucoid impaction that can lead to bronchiectasis, fibrosis, and respiratory compromise.

History and exam

Key diagnostic factors

hx of asthma
hx of cystic fibrosis (CF)
teenage and young adulthood
hx of atopy
coughing
mucus plugs
wheezing

Other diagnostic factors

fever
pleuritic chest pain
finger clubbing
cyanosis
weight loss

Risk factors

asthma
cystic fibrosis (CF)
atopy
HLA-DR2- and HLA-DR5-positive
IL-10 promoter polymorphisms
surfactant protein polymorphisms
CFTR gene

Diagnostic investigations

1st investigations to order

skin test for Aspergillus fumigatus sensitivity
serum total IgE
FBC with peripheral blood eosinophil count
chest x-ray

Investigations to consider

serum-specific IgG
serum-specific IgE
sputum culture and microscopy
CT chest
HLA antigens

Treatment algorithm

ACUTE

stage 1: acute

stage 2: remission

stage 3: exacerbation

stage 4: corticosteroid-dependent asthma

stage 5: end-stage fibrosis

Contributors

AuthorsVIEW ALL

Cristine Radojicic, MD

Staff Physician

Department of Pulmonary, Allergy and Critical Care

Cleveland Clinic

Cleveland

OH

Disclosures

CR is on the Advisory Boards for CSL Behring and Shire (advising on treatments for hereditary angio-oedema).

Peer reviewersVIEW ALL

Martin Schöni, MD

Professor

Department of Pediatrics

University of Bern

Bern

Switzerland

Disclosures

MS declares that he has no competing interests.

Jordan Fink, MD

Professor of Pediatrics

Allergy-Immunology Division

Medical College of Wisconsin

Milwaukee

WI

Disclosures

JF is an author of a number of references cited in this monograph.

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