ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS
Ashok Shah
Professor, Department of Respiratory Medicine,
Vallabhbhai Patel Chest Institute,
University of Delhi,
Delhi, India
Allergic bronchopulmonary aspergillosis (ABPA) is the best known form of allergic
aspergillosis, which also includes Aspergillus-induced (IgE-mediated) asthma, hypersensitivity
pneumonitis and allergic Aspergillus sinusitis (AAS) 1. An immunologically mediated lung
disease, ABPA occurs predominantly in asthmatics, and has a worldwide incidence2. This
potentially destructive lung disease is known to occur in patients with cystic fibrosis3 and
familial occurrence has also been recorded4.
To establish the diagnosis, a set of diagnostic criteria5,6 is required as there is no single
test, apart from demonstration of central bronchiectasis with normal tapering bronchi, a
feature considered to be pathognomonic, that confirms the diagnosis. Radiologically, ABPA is
characterised
by
‘transient
pulmonary
infiltrates’
or
‘fleeting
shadows’
on
serial
roentgenograms7. We have earlier highlighted that CT of the thorax can provide a sensitive
method for the assessment of bronchial, parenchymal and pleural abnormalities in patients
with ABPA, and should constitute a part of the diagnostic work-up of the disease along with
plain chest roentgenograms8,9.
. A group of patients presenting at an earlier stage of the disease or with a milder form
of the disease may not have CB. Such seropositive patients can be categorised as ABPA-S,
and treatment commenced to prevent further lung damage10. Oral corticosteroids, till date, are
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the cornerstone for the management of ABPA. Although the role of antifungals is still debated,
they might improve short-term symptoms and reduce the frequency of exacerbations 11.
Concomitant occurrence of ABPA and AAS is now being increasingly recognised4,12.
Coexistent ABPA with aspergilloma, though infrequent, has also been reported 13; while
association of ABPA, AAS and aspergilloma in a single patient has been documented only
twice14,15.The co-occurrence of an aspergilloma is thought to increase the severity of the
disease
16,17.
In conclusion, ABPA must be sought for in all asthmatics with a positive skin
prick test to Aspergillus antigens and AAS must be excluded in patients with ABPA18.
References
1. Shah A. Allergic bronchopulmonary aspergillosis: an Indian perspective. Curr Opin Pulm Med 2007;
13: 72-80.
2. Shah A, Panjabi C. Allergic bronchopulmonary aspergillosis: A review of a disease with a worldwide
distribution. J Asthma 2002; 39: 273-289.
3. Greenberger PA. Allergic bronchopulmonary aspergillosis. J Allergy Clin Immunol 2002; 110: 685692.
4. Shah A, Kala J, Sahay S, Panjabi C. Frequency of familial occurrence in 164 patients with allergic
bronchopulmonary aspergillosis. Ann Allergy Asthma Immunol 2008; 101: 363-369.
5. Rosenberg M, Patterson R, Mintzer R, Cooper BJ, Roberts M, Harris KE. Clinical and immunologic
criteria for the diagnosis of allergic bronchopulmonary aspergillosis. Ann Intern Med 1977; 86: 405414.
6. Wang JLF, Patterson R, Rosenberg M, Roberts M, Cooper BJ. Serum IgE and IgG antibody activity
against Aspergillus fumigatus as a diagnostic aid in allergic bronchopulmonary aspergillosis. Am
Rev Respir Dis 1978; 117: 917-927.
7. Shah A. Allergic bronchopulmonary and sinus aspergillosis: the roentgenologic spectrum. Front
Biosci 2003; 8: e138-146.
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8. Panchal N, Pant CS, Bhagat R, Shah A. Central bronchiectasis in allergic bronchopulmonary
aspergillosis: comparative evaluation of computed tomography of the thorax with bronchography.
Eur Respir J 1994; 7: 1290-1293.
9. Panchal N, Bhagat R, Pant C, Shah A. Allergic bronchopulmonary aspergillosis: The spectrum of
computed tomography appearances. Respir Med 1997; 91: 213-219.
10.
Patterson R, Greenberger PA, Halwig JM, Liotta JL, Roberts M. Allergic bronchopulmonary
aspergillosis: Natural history and classification of early disease by serologic and roentgenographic
studies. Arch Intern Med 1986; 146: 916-918
11. Wark PA, Gibson PG, Wilson AJ. Azoles for allergic bronchopulmonary aspergillosis associated
with asthma. Cochrane Database Syst Rev 2004; 3: CD001108.
12. Shah A, Panchal N, Agarwal AK. Concomitant allergic bronchopulmonary aspergillosis and
allergic Aspergillus sinusitis: A review of an uncommon association. Clin Exp Allergy 2001; 31:
1896 - 1905.
13. Shah A, Khan ZU, Chaturvedi S, Ramchandran S, Randhawa HS, Jaggi OP. Allergic
bronchopulmonary aspergillosis with co-existent aspergilloma. A long term follow up. J Asthma
1989; 26:109-115.
14. Bhagat R, Shah A, Jaggi OP, Khan ZU. Concomitant allergic bronchopulmonary aspergillosis and
allergic Aspergillus sinusitis with an operated aspergilloma. J Allergy Clin Immunol 1993; 91:
1094-1096.
15. Shah A. Concurrent allergic bronchopulmonary aspergillosis and aspergilloma: is it a more severe
form of the disease? [editorial]. Eur Respir Rev 2010; 19: 118, 261–263
16. Agarwal R, Aggarwal AN, Garg M, Saikia B, Gupta D, Chakrabarti A. Allergic bronchopulmonary
aspergillosis with aspergilloma: An immunologically severe disease with poor outcome.
Mycopathologica 2012 ; 174 : 193 - 20
17. Shah A, Panjabi C. Contemporaneous occurrence of allergic bronchopulmonary aspergillosis,
allergic Aspergillus sinusitis and aspergilloma. Ann Allergy Asthma Immunol 2006; 96: 874-878.
18. Maurya V, Gugnani SC, Sarma PU, Madan T, Shah A. Sensitization to Aspergillus antigens and
occurrence of allergic bronchopulmonary aspergillosis in patients with asthma. Chest 2005; 127:
1252-1259.
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