From the Guidelines
Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to the fungus Aspergillus fumigatus that occurs primarily in patients with asthma or cystic fibrosis, characterized by a complex immune response involving fungal sensitization, eosinophilia, and bronchiectasis. The diagnosis of ABPA involves a combination of clinical, radiological, and immunological criteria, including a mandatory demonstration of fungal sensitization and serum total IgE ≥500 IU·mL−1, as well as two of the following: fungal-specific IgG, peripheral blood eosinophilia, or suggestive imaging 1.
Key Characteristics of ABPA
- Hypersensitivity reaction to Aspergillus fumigatus
- Primarily occurs in patients with asthma or cystic fibrosis
- Characterized by fungal sensitization, eosinophilia, and bronchiectasis
- Diagnosis involves clinical, radiological, and immunological criteria
Diagnostic Criteria
- Fungal sensitization
- Serum total IgE ≥500 IU·mL−1
- Two of the following: fungal-specific IgG, peripheral blood eosinophilia, or suggestive imaging
Treatment Approach
The treatment of ABPA involves a dual approach of controlling inflammation and managing the underlying condition, with oral corticosteroids and itraconazole being the mainstays of therapy. For acute ABPA, oral prednisolone or itraconazole monotherapy is recommended, while for recurrent ABPA exacerbations, a combination of prednisolone and itraconazole is suggested 1. Regular monitoring of pulmonary function, IgE levels, and chest imaging is essential to assess treatment response and detect exacerbations early.
Treatment Options
- Oral corticosteroids
- Itraconazole
- Combination of prednisolone and itraconazole for recurrent exacerbations
- Regular monitoring of pulmonary function, IgE levels, and chest imaging
The management of ABPA requires a comprehensive approach, taking into account the patient's underlying condition, the severity of the disease, and the potential for treatment-related adverse effects 1. By prioritizing the most recent and highest-quality evidence, clinicians can provide optimal care for patients with ABPA, reducing the risk of morbidity, mortality, and improving quality of life.
From the Research
Definition and Characteristics of ABPA
- Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disease characterized by recurrent pulmonary opacities and bronchiectasis caused by Type 1 hypersensitivity to A. fumigatus 2.
- ABPA is a complex allergic inflammatory reaction of airways against Aspergillus, affecting patients with chronic respiratory diseases such as asthma and cystic fibrosis 3.
- The disease is manifesting with poorly controlled asthma, recurrent pulmonary infiltrates, and bronchiectasis 4.
Pathogenesis of ABPA
- Immunoglobulins against A. fumigatus, Th2-derived cytokines such as IL-4, IL-5, and IL-13, and eosinophilic inflammation play a role in the pathogenesis of the disease 2.
- The innate and adaptive immune responses (Th2 CD4(+) T cell responses) of the lung are activated by inhaled conidia of A. fumigatus, leading to the release of antigens 4.
Diagnosis and Treatment of ABPA
- Diagnostic criteria for ABPA are regularly revised and are mainly based on the elevation of total and specific IgE against Aspergillus fumigatus and the presence of suggestive CT abnormalities such as mucoid impaction and consolidations 3.
- The main treatment of ABPA for exacerbations and remissions is oral corticosteroids (OCS), and azole antifungal agents represent an alternative for the treatment of exacerbations 3, 5.
- Monoclonal antibody treatments targeting IL-4, IL-5, IL-13, and IgE have been used in patients with ABPA, showing reduction in exacerbations, OCS requirements, and improvement in asthma symptoms and pulmonary function parameters 2.
- Treatment of ABPA also includes eviction of mold and pharmacological therapy, with asthma biologics being of interest, although their place remains to be determined 3, 6.