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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 43-46

A study of clinicoradiological profile in cases of allergic bronchopulmonary aspergillosis


Department of Respiratory Medicine, AMC MET Medical College, Ahmedabad, Gujarat, India

Date of Submission13-Jun-2021
Date of Decision16-Nov-2021
Date of Acceptance24-Nov-2021
Date of Web Publication04-Jan-2022

Correspondence Address:
Dr. Savita Jindal
A-12 Orchid Greens Girdhar Nagar Circle, Shahibaug, Ahmedabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrc.ijrc_73_21

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  Abstract 


Introduction: Allergic bronchopulmonary aspergillosis (ABPA) is an immunologic pulmonary disorder caused by a complex hypersensitivity response to inhaled fungal antigens. ABPA occurs most commonly in immunocompetent patients and complicates 1% to 2% of cases of persistent asthma and 7% to 14% of cases of chronic steroid-dependent asthma. Aim: The aim of this study was to study the clinical and radiological profile of patients and to study the serological correlation of ABPA. Methodology: This was a retrospective study done over 6 months from June 2020 to December 2020. Patients who were confirmed cases of ABPA according to the International Society for Human and Animal Mycology criteria were enrolled for the study. Patients' demographic data, pathological, and radiological test results were collected and analyzed. Pre- and post-bronchodilator spirometry of the patients were examined and asthma control was calculated. Results: In the present study, 23 patients were studied. Most patients were young, the mean age was 35.7 years with a female predominance of 56.5%. The most common symptom was cough in 91.3% of patients. All patients had bronchial asthma as a predisposing factor. The mean absolute eosinophil count and mean serum immunoglobulin E were 534 cells/μL and 2270 UI/ml, respectively. About 82.6% of participants in the study had spirometry suggestive of obstructive pattern. Bronchiectasis and parenchymal opacities were the most common radiological abnormality seen. Conclusion: The diagnosis of ABPA must be considered when treating difficult to control asthma. A delay in diagnosis can lead to decreased asthma control, worsening of lung function, sometimes leading to irreversible changes, poor quality of life, and increased cost of treatment.

Keywords: Allergic bronchopulmonary aspergillosis, asthma, International Society for Human and Animal Mycology


How to cite this article:
Parikh AJ, Tripathi S, Jindal S, Kothari D, Dhameliya M. A study of clinicoradiological profile in cases of allergic bronchopulmonary aspergillosis. Indian J Respir Care 2022;11:43-6

How to cite this URL:
Parikh AJ, Tripathi S, Jindal S, Kothari D, Dhameliya M. A study of clinicoradiological profile in cases of allergic bronchopulmonary aspergillosis. Indian J Respir Care [serial online] 2022 [cited 2022 Jan 26];11:43-6. Available from: http://www.ijrc.in/text.asp?2022/11/1/43/334805




  Introduction Top


Allergic bronchopulmonary aspergillosis (ABPA) is an immunologic pulmonary disorder caused by hypersensitivity to Aspergillus fungus. Clinically, patient presents with chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis.[1] The population prevalence of ABPA is not clearly known, but it almost exclusively occurs in patients with asthma and cystic fibrosis.[2] This disorder needs to be diagnosed before bronchiectasis develops because the occurrence of bronchiectasis is associated with poorer outcomes. As many patients with ABPA may be minimally symptomatic or asymptomatic, a high index of suspicion for ABPA should be maintained while managing any patient with asthma whatever the severity of control.[2] This underscores the need for routine screening of all patients with asthma and cystic fibrosis to rule out ABPA. This study was done to try to know the clinical and radiological profile of patients and to study the serological correlation of ABPA.


  Methodology Top


A retrospective study was conducted in the Department of Respiratory Medicine for 6 months from June 2020 to December 2020 after approval from the institutional review board. Patients who were >18 years of age, of either gender and who were confirmed to have ABPA according to the International Society for Human and Animal Mycology criteria[3] [Table 1] were enrolled in the study. Their demographic data, pathology test results such as complete blood count, absolute eosinophil count, serum immunoglobulin E (IgE), specific IgE and IgG for aspergillus fumigatus, sputum for Acid-fast bacilli, sputum for culture and sensitivity, and sputum for fungus, radiological tests such as chest X-ray and high-resolution computed tomography (CT) of the thorax were collected, and the data were analyzed. Pre- and post-bronchodilator spirometry and asthma control of all the patients were calculated.
Table 1: International Society for Human and Animal Mycology criteria for the diagnosis of allergic bronchopulmonary aspergillosis

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  Results Top


The clinical characteristics and laboratory findings in 23 patients with ABPA are given in [Table 2]. The spirometry findings in patients with ABPA are listed in [Table 3]. The radiological findings in patients with ABPA are shown in [Table 4]. The chest radiographic findings in ABPA may be broadly classified as transient or fixed.[4] The characteristic fleeting opacities are found during ABPA exacerbations, whereas fixed abnormalities are encountered in the advanced stages [Figure 1]. The most common finding is that of a normal chest radiograph,[5] suggesting that it is not the best investigation for delineating the radiological abnormalities of ABPA. However, a chest radiograph is useful in follow-up as transient abnormalities disappear after the institution of therapy.
Table 2: Clinical characteristics and laboratory findings in 23 patients with allergic bronchopulmonary aspergillosis

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Table 3: Spirometry findings in patients with allergic bronchopulmonary aspergillosis (n=23)

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Table 4: Radiological findings in patients with allergic bronchopulmonary aspergillosis (n=23)

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Figure 1: This is chest X-ray showing bilateral opacities and bronchiectasis

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CT thorax is currently the imaging modality of choice for ABPA.[6] The most common finding on CT chest is bronchiectasis [Figure 2]. Central bronchiectasis is believed to be characteristic for the diagnosis of ABPA, and bronchiectasis can be peripheral also. The pathognomonic radiological finding in ABPA is high-attenuation mucus, which is visually denser than the paraspinal skeletal muscle which indicates ABPA as the etiology of the underlying bronchiectasis.[7]
Figure 2: This is a high-resolution computed tomography thorax showing central bronchiectasis. Mucoid impaction and dilated bronchi are also shown

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Other CT findings include the presence of consolidation, mucoid impaction, centrilobular nodules, parenchymal opacities, and mosaic attenuation. The uncommon radiologic manifestations include perihilar opacities simulating hilar lymphadenopathy, miliary nodules, pleural effusion, lung collapse, and pulmonary masses. ABPA can present without any radiological manifestations, which emphasizes fact that the diagnosis of ABPA is primarily immunological. [Table 5] shows the level of asthma control as assessed using the asthma control test (ACT).
Table 5: Level of asthma control assessed using asthma control test

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  Discussion Top


ABPA is a disorder caused by a complex hypersensitivity response to inhaled fungal antigens.[8] ABPA occurs most commonly in immunocompetent patients and complicates 1% to 2% of cases of persistent asthma and 7% to 14% of cases of chronic steroid-dependent asthma.[8] The features of ABPA are believed to result from a complex immunologic reaction to chronic airway colonization by aspergillus that includes type 1, type 3, and type 4 immune responses.[4]

Most of the patients in the present study were young (mean age = 35.7 years) which were much younger as compared to previous studies on ABPA, where the mean age of patients was more than 50 years. The number of women diagnosed to have ABPA exceeded men, unlike in previous studies.[5],[6],[7],[9],[10] A comparison of previous studies with the present study is given in [Table 6]. All patients in the study were having bronchial asthma and no patients of cystic fibrosis were seen paralleling the low prevalence of cystic fibrosis and high prevalence of bronchial asthma in India. Most of the patients (about 40%) in the study were having past history of tuberculosis.
Table 6: Comparison of the present study with recent case series of bronchopulmonary aspergillosis from different parts of the world

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Most of the patients (about 87%) were having obstructive pattern on pulmonary function testing which was due to all patients in the study having bronchial asthma. Even then, a restrictive pattern was seen in pulmonary function testing of 13% of patients in the study, in whom past pulmonary function testing showed obstructive pattern with reversibility. This might be due to the progression of asthma.

The most common radiographic abnormality seen in patients with ABPA was bronchiectasis and was seen in seven patients. Opacities were seen in seven patients followed by consolidation in five patients. The mucus pulling was seen only in two patients in the study.

All the patients in the study were symptomatic for more than 4 weeks. Furthermore, all the patients in the study had past history of use of broad-spectrum antibiotics and/or oral steroids for controlling asthma exacerbation. When asthma control was checked as per the ACT, only four patients (about 17%) had well-controlled asthma. The remaining 19 patients (about 83%) were having not so well-controlled asthma despite spirometry suggestive of mild obstruction in 12 patients.

The possibility of coexisting ABPA must be borne in mind and actively searched for when treating difficult to control asthma. A delay in diagnosis can lead to decreased asthma control, progressive worsening of lung function sometimes leading to irreversible changes, poor quality of life, and increased cost of treatment.

Since the study duration was only 6 months, the prognosis, response to treatment, and clinicoradiological profile changes in response to treatment could not be studied. As the study was conducted during the COVID-19 pandemic, the number of participants was less and those patients who came COVID-19-positive were not taken in the study.

Future studies on ABPA can be designed to study the long-term effect of treatment on clinicoradiological profile and prognosis, how COVID-19 pneumonia changes the pattern of disease profile, natural history of ABPA in patients with asthma, and cystic fibrosis patients in India.


  Conclusion Top


The diagnosis of ABPA must be considered when treating difficult to control asthma. A delay in diagnosis can lead to decreased asthma control, worsening of lung function sometimes leading to irreversible changes, poor quality of life, and increased cost of treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Greenberger PA. Allergic bronchopulmonary aspergillosis. J Allergy Clin Immunol 2002;110:685-92.  Back to cited text no. 1
    
2.
Agarwal R. Allergic bronchopulmonary aspergillosis. Chest 2009;135:805-26.  Back to cited text no. 2
    
3.
Bains SN, Judson MA. Allergic bronchopulmonary aspergillosis. Clin Chest Med 2012;33:265-81.  Back to cited text no. 3
    
4.
Agarwal R, Sehgal IS, Dhooria S, Aggarwal AN. Developments in the diagnosis and treatment of allergic bronchopulmonary aspergillosis. Expert Rev Respir Med 2016;10:1317-34.  Back to cited text no. 4
    
5.
Kurhade AM, Deshmukh JM, Fule RP, Chande C, Akulwar S. Mycological and serological study of pulmonary aspergillosis in central India. Indian J Med Microbiol 2002;20:141-4.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Shahid M, Malik A, Bhargava R. Prevalence of aspergillosis in chronic lung diseases. Indian J Med Microbiol 2001;19:201-5.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Denning DW, Riniotis K, Dobrashian R, Sambatakou H. Chronic cavitary and fibrosing pulmonary and pleural aspergillosis: Case series, proposed nomenclature change, and review. Clin Infect Dis 2003;37 Suppl 3:S265-80.  Back to cited text no. 7
    
8.
Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Aspergillus hypersensitivity and allergic bronchopulmonary aspergillosis in patients with bronchial asthma: Systematic review and meta-analysis. Int J Tuberc Lung Dis 2009;13:936-44.  Back to cited text no. 8
    
9.
Gupta PR, Vyas A, Meena RC, Sharma S, Khayam N, Subramanian IM, et al. Clinical profile of pulmonary aspergilloma complicating residual tubercular cavitations in Northen Indian patients. Lung India 2010;27:209-11.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Nam HS, Jeon SW, Suh GY, Chung MP, Kim H, Kwon OJ, et al. Clinical characteristics and treatment outcome of chronic necrotising pulmonary aspergillosis: A review of 43 cases. Int J Infect Dis 2010;14:e477-82.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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