Allergic bronchopulmonary aspergillosis

Background

• Colonization of the airways prompting an allergic reaction that worsens asthma
• Caused by a Th2 response to Aspergillus, usually in patients with asthma or cystic fibrosis

Clinical Manifestations

• Characterized by poorly-controlled asthma or pneumonia, mucoid impaction, persistent eosinophilia
• The course is characterized by exacerbations and remissions, leading to eventual pulmonary fibrosis and chronic pulmonary aspergillosis
• The most important diagnostic criterion is elevated Aspergillus-specific IgE
• Supportive criteria include elevated total IgE >417 IU/mL, Aspergillus-specific IgG, Aspergillus serum precipitins, positive skin prick test for Aspergillus, or eosinophilia
• Other findings include Aspergillus on sputum culture, brown mucous plugs with dead eosinophils, and CXR or CT showing bronchiectasis

Management

• Indications for treatment
  • Diagnose with Aspergillus-IgE
  • If ongoing symptoms despite appropriate management of asthma (including oral steroids), treat with itraconazole
  • If CF patient has frequent exacerbations or falling FEV1, treat with itraconazole
• Itraconazole 200 mg/day for 16 weeks, which decreases steroid use and increases patient function