What is the difference between aspergilloma and Allergic Bronchopulmonary Aspergillosis (ABPA)?

From the Guidelines

Aspergilloma and Allergic Bronchopulmonary Aspergillosis (ABPA) are two distinct conditions caused by Aspergillus fungi, but they differ significantly in their pathophysiology, presentation, and treatment, with aspergilloma representing fungal colonization of a cavity and ABPA being an immune-mediated inflammatory response to Aspergillus antigens in the airways. The key differences between the two conditions are:

• Pathophysiology: Aspergilloma is a fungal ball (mycetoma) that develops in pre-existing lung cavities, typically in patients with prior lung diseases like tuberculosis or sarcoidosis, whereas ABPA is an allergic hypersensitivity reaction to Aspergillus antigens in patients with asthma or cystic fibrosis.
• Presentation: Patients with aspergilloma may be asymptomatic or present with hemoptysis, cough, or weight loss, while patients with ABPA typically present with worsening asthma symptoms, wheezing, productive cough, and sometimes bronchiectasis.
• Treatment: Aspergilloma treatment is often conservative unless severe hemoptysis occurs, in which case surgical resection may be necessary, whereas ABPA treatment focuses on reducing inflammation and suppressing the immune response, primarily with oral corticosteroids and antifungal therapy. According to the most recent guidelines, the diagnosis of ABPA requires a combination of characteristics, including fungal sensitisation, serum total IgE ≥500 IU·mL−1, and two of the following: fungal-specific IgG, peripheral blood eosinophilia, or suggestive imaging 1. In contrast, aspergilloma is typically diagnosed based on the presence of a fungal ball in a pre-existing lung cavity, with or without symptoms. The treatment of ABPA involves oral prednisolone or itraconazole monotherapy for acute ABPA, with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations 1. In summary, aspergilloma and ABPA are two distinct conditions that require different diagnostic and therapeutic approaches, with a focus on reducing morbidity, mortality, and improving quality of life. Some key points to consider when diagnosing and treating these conditions include:
• The use of fungus-specific IgE and serum total IgE to diagnose ABPA 1
• The importance of reducing inflammation and suppressing the immune response in ABPA treatment 1
• The need for surgical resection in cases of severe hemoptysis due to aspergilloma 1
• The use of antifungal medications like itraconazole or voriconazole in symptomatic cases of aspergilloma 1.

From the Research

Difference between Aspergilloma and Allergic Bronchopulmonary Aspergillosis (ABPA)

• Aspergilloma is a fungal infection caused by Aspergillus species, which can form a fungal ball in the lungs, whereas ABPA is a hypersensitivity reaction to Aspergillus fumigatus in patients with asthma and cystic fibrosis 2.
• ABPA is characterized by chronic cough, wheezing, and dyspnea due to uncontrolled asthma, with expectoration of brownish mucus plugs and radiographic findings of fleeting pulmonary infiltrates, bronchiectasis, and mucus impaction 2, 3.
• The pathophysiology of ABPA involves a complex interplay between the fungus and the host immune response, causing persistent inflammation and tissue damage 2.
• Aspergilloma, on the other hand, is typically associated with a localized fungal infection, which can cause symptoms such as cough, chest pain, and hemoptysis.
• The treatment of ABPA aims to reduce symptoms, prevent disease progression, and minimize the future risk of exacerbations, using systemic glucocorticoids or antifungal agents to suppress the inflammatory response or fungal growth 2, 3.
• In contrast, the treatment of aspergilloma usually involves surgical removal of the fungal ball or antifungal therapy.

Clinical Characteristics of ABPA

• ABPA is often misdiagnosed due to its diverse disease manifestations and incomplete knowledge among physicians 4.
• Patients with ABPA may have a high misdiagnosis rate, with some being misdiagnosed as having tuberculosis or other conditions 4.
• The diagnosis of ABPA requires a combination of clinical, radiological, and immunological findings, including elevated total serum IgE levels and eosinophil count 2, 4.
• The treatment of ABPA is not standardized, and patients who do not fully meet the diagnostic criteria may be more likely to receive inadequate treatment, leading to poor prognosis 4.

Recent Developments in ABPA

• Recent research has described the clinical features and natural history of ABPA complicating asthma in children and the elderly 5.
• The utility of recombinant fungal antigens in the diagnosis of ABPA has been established, and newer, more sensitive criteria for the diagnosis of ABPA have been proposed 5.
• There is an unmet need for research into the genetic predisposition, pathophysiology, and treatment of ABPA, particularly in patients with other obstructive lung diseases such as COPD and noncystic fibrosis bronchiectasis 5.