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Allergic bronchopulmonary aspergillosis is a hypersensitivity lung disease that results from exposure to Aspergillus fumigatus and occurs primarily in people with asthma or with cystic fibrosis. These guidelines were developed via a consensus conference of experts in 2003.
Stevens DA, Moss RB, Kurup VP, Knutsen AP, Greenberger P, Judson MA, Denning DW, Crameri R, Brody AS, Light M, Skov M, Maish W, Mastella G, and participants in the Cystic Fibrosis Foundation Consensus Conference. Allergic Bronchopulmonary Aspergillosis in Cystic Fibrosis-State of the Art: Cystic Fibrosis Foundation Consensus Conference. Clin Infect Dis. 2003 Oct; 37 (Suppl 3), S225-64.PMID: 12975753
The 2003 recommendations addressed diagnostic criteria, screening, imaging, and treatment recommendations. Since 2003, there has been advancement in diagnostic ability via serology and immunologic testing. Most advancement has occurred in the treatment options. There has been more clarity in steroid dosing, but additional treatment options, including intravenous (IV) pulse steroids, systemic and inhaled antifungals, and anti-immunoglobulin E (IgE) therapy, have been explored. Future directions include the need for improved animal models as well as controlled treatment studies.
Allergic bronchopulmonary aspergillosis (ABPA), a lung disease of hypersensitivity to Aspergillus fumigatus (A. fumigatus) that primarily occurs in people with asthma or with cystic fibrosis, is seen in 2 to 19 percent of people with CF. People with CF may be predisposed to ABPA because of abnormal airway surface liquid and CF mucus. The disease is characterized by a variety of clinical and immunologic responses to A. fumigatus antigens. Clinical manifestations include:
The diagnosis of ABPA in people with CF is difficult and often delayed because of shared clinical features. ABPA has been associated with accelerated deterioration in lung disease, so timely diagnosis and treatment are imperative.
An expert panel was convened and a consensus conference held in 2001. The panel used the United States Preventive Services Task Force, 1989 grading methodology.
Acute or subacute clinical deterioration (cough, wheeze, exercise intolerance, exercise-induced asthma, decline in pulmonary function, increased sputum) not attributable to another etiology.
Serum total IgE concentration of >1000 IU per mL unless patient is receiving systemic corticosteroids (if so, retest when steroid treatment is discontinued).
Immediate cutaneous reactivity to Aspergillus (prick skin test wheal of ≥3 mm in diameter with surrounding erythema, while the patient is not being treated with systemic antihistamines) or in vitro presence of serum IgE antibody to A. fumigatus.
Precipitating antibodies to A. fumigatus or serum IgG antibody to A. fumigatus by an in vitro test.
New or recent abnormalities on chest radiography (infiltrates or mucus plugging) or chest CT (bronchiectasis) that have not cleared with antibiotics and standard physiotherapy.
Acute or subacute clinical deterioration (cough, wheeze, exercise intolerance, exercise-induced asthma, change in pulmonary function, or increased sputum production) not attributed to another etiology.
Total serum IgE concentration of >500 IU per mL. If ABPA is suspected and the total IgE level is 200-500 IU per mL, repeat testing in one to three months is recommended. If patient is taking steroids, repeat when steroid treatment is discontinued.
Immediate cutaneous reactivity to Aspergillus (prick test wheal >3 mm with surrounding erythema, off systemic antihistamines) or in vitro demonstration of IgE antibody to A. fumigatus.
One of the following:
Maintain a high level of suspicion for ABPA in patients >6 years of age.
Determine the total serum IgE concentration annually. If the total serum IgE concentration is >500 IU per mL, determine immediate cutaneous reactivity to A. fumigatus or use an in vitro test for IgE antibody to A. fumigatus. If results are positive, consider diagnosis on the basis of minimal criteria.
If the total serum IgE concentration is 200-500 IU per mL, repeat the measurement if there is increased suspicion for ABPA, such as by a disease exacerbation, and perform further diagnostic tests (immediate skin test reactivity to A. fumigatus, in vitro test for IgE antibody to A. fumigatus, A. fumigatus precipitins, or serum IgG antibody to A. fumigatus and chest radiography).
First line: systemic steroids -- prednisone 0.5-2.0 mg per kg per day, one to two weeks -- then attempt to taper within two to three months.
Second line: antifungal -- oral itraconazole 5 mg per kg per day (max 400 mg per day) for three to six months (if slow or poor response to steroids, relapse, or steroid toxicity).
Bronchodilators, inhaled steroids, antiasthma drugs only if indicated for asthma.
New animal models are needed to better represent ABPA in CF. For example, Urb et al. developed a promising murine model for chronic Aspergillus airway infection (Infect Immun 2015, 83, 3590).
New and/or validated ways to better classify and distinguish Aspergillus lung phenotypes (i.e., colonization, infection/bronchitis, sensitization, and ABPA) are needed. For example, Baxter et al. added sputum Aspergillus PCR and galactomannan to standard serologic assays (J Allergy Clin Immunol 2013, 132, 560-6.e10). Gernez et al. showed diagnostic accuracy of basophil activation test (Eur Resp J 2016, 47, 177).
There is continued need for randomized placebo-controlled trials testing the efficacy of antifungals and Th2-directed biologics in people with ABPA CF.
Relevant manuscripts published after the original guidelines are listed below. These manuscripts have not been reviewed or endorsed by the guidelines committee.
Caroline Okorie, M.D., MPH and Richard B. Moss, M.D. (Stanford University)
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