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Allergic aspergillosis of the respiratory tract

Ashok Shah, Chandramani Panjabi
European Respiratory Review 2014 23: 8-29; DOI: 10.1183/09059180.00007413
Ashok Shah
1Dept of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, and 2Dept of Respiratory Medicine, Mata Chanan Devi Hospital, New Delhi, India.
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  • For correspondence: ashokshah99@yahoo.com
Chandramani Panjabi
1Dept of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, and 2Dept of Respiratory Medicine, Mata Chanan Devi Hospital, New Delhi, India.
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Figures

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  • Figure 1.
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    Figure 1.

    Chest radiograph showing a non-homogeneous opacity in the right mid zone with perihilar patchy infiltrates in the left mid and lower zones. Transient pulmonary infiltrates or fleeting shadows that are characteristic of allergic bronchopulmonary asperillosis are visible.

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    Figure 2.

    Chest radiograph of the same patient as in figure 1 taken 18 months later showing a large consolidation in the right upper and mid zones with partial resolution of the left-sided perihilar infiltrate. In addition, blunting of the right costophrenic angle suggestive of pleural effusion can be seen. Transient pulmonary infiltrates or fleeting shadows that are characteristic of allergic bronchopulmonary asperillosis are visible.

  • Figure 3.
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    Figure 3.

    Chest radiograph showing characteristic wine glass opacity in the left upper zone. A non-homogeneous consolidation is also seen on the right side.

  • Figure 4.
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    Figure 4.

    a) Computed tomography of the thorax showing signet ring appearances, indicative of central bronchiectasis. Mucoid impaction and dilated bronchi are also visible. b) Computed tomography of the thorax showing string of pearls appearances bilaterally, indicative of central bronchiectasis.

  • Figure 5.
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    Figure 5.

    High-resolution computed tomography of the thorax a) mediastinal window and b) corresponding section on the lung window showing high attenuation mucus impaction.

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    Figure 6.

    Computed tomography of the paranasal sinuses showing hyperdense lesions in the frontal, ethmoid and maxillary sinuses bilaterally, suggestive of inspissated secretions.

Tables

  • Figures
  • Table 1. Aspergillus-associated respiratory disorders
    Allergic aspergillosis
        (IgE-mediated) Aspergillus-induced asthma
        Allergic bronchopulmonary aspergillosis
        Allergic Aspergillus sinusitis
        Hypersensitivity pneumonitis
    Saprophytic colonisation
        Aspergilloma
            Simple
            Complex (chronic cavitary pulmonary aspergillosis)
        Sinus fungal balls
    Invasive disease
        Invasive pulmonary aspergillosis
            Acute
            Subacute (chronic necrotising pulmonary aspergillosis)
        Acute fulminant invasive sinusitis
        Chronic invasive sinusitis
        Granulomatous invasive sinusitis
    • Information from [1, 2].

  • Table 2. Evolving diagnostic criteria for allergic bronchopulmonary asperillosis (ABPA)
    Rosenberg–Patterson criteria [73,#74]
        Major criteria
            Asthma
            Presence of transient pulmonary infiltrates (fleeting shadows)
            Immediate cutaneous reactivity to Aspergillus fumigatus
            Elevated total serum IgE
            Precipitating antibodies against A. fumigatus
            Peripheral blood eosinophilia
            Elevated serum IgE and IgG to A. fumigatus
            Central/proximal bronchiectasis with normal tapering of distal bronchi
        Minor criteria
            Expectoration of golden brownish sputum plugs
            Positive sputum culture for Aspergillus species
            Late (Arthus type) skin reactivity to A. fumigatus
    Minimal essential criteria [19]
        Asthma
        Immediate cutaneous reactivity to A. fumigatus
        Total serum IgE >1000 ng·mL−1 (417 kU·L−1)
        Elevated specific IgE-/IgG to A. fumigatus
        Central bronchiectasis in the absence of distal bronchiectasis
    Truly minimal criteria [18]
        Asthma
        Immediate cutaneous reactivity to A. fumigatus
        Total serum IgE >1000 ng·mL−1 (417 kU·L−1)
        Central bronchiectasis in the absence of distal bronchiectasis
    ISHAM working group [68]
        Predisposing conditions
            Bronchial asthma
            Cystic fibrosis
        Obligatory criteria (both should be present)
            Type I Aspergillus skin test positive (immediate cutaneous hypersensitivity to Aspergillus antigen) or elevated IgE levels against A. fumigatus
            Elevated total IgE levels (>1000 IU·mL−1)#
        Other criteria (at least two of three)
            Presence of precipitating or IgG antibodies against A. fumigatus in serum
            Radiographic pulmonary opacities consistent with ABPA
            Total eosinophil count >500 cells·μL−1 in steroid naïve patients (may be historical)
    • ISHAM: International Society for Human and Animal Mycology. #: if the patient meets all other criteria an IgE value <1000 IU·mL−1 may be acceptable.

  • Table 3. Radiological changes in allergic bronchopulmonary asperillosis
    Plain chest radiology
        Transient changes
            Perihilar infiltrates simulating adenopathy
            Air–fluid levels from dilated central bronchi filled with fluid and debris
            Massive consolidation: unilateral or bilateral
            Radiological infiltrates
            “Toothpaste” shadows due to mucoid impaction in damaged bronchi
            “Gloved finger” shadows from distally occluded bronchi filled with secretions
            “Tramline” shadows representing oedema of the bronchial walls
            Collapse: lobar or segmental
        Permanent changes
            Central bronchiectasis with normal peripheral bronchi
            Parallel-line shadows representing bronchial widening
            Ring-shadows 1–2 cm in diameter representing dilated bronchi en face
            Pulmonary fibrosis
            Late changes: cavitation, contracted upper lobes and localised emphysema
    Computed tomography findings
        Bronchial abnormalities
            Bronchiectasis, usually central, as characterised by the “signet ring” and “string of pearls” appearances
            Dilated bronchi with or without air–fluid levels
            Totally occluded bronchi
            Bronchial wall thickening
            Parallel-line opacities extending to the periphery
            High attenuation mucus plugs
        Parenchymal changes
            Consolidation
            Non-homogeneous patchy opacities
            Parenchymal scarring of varying extent
            Segmental or lobar collapse
            Cavitation
            Emphysematous bullae
        Pleural involvement
            Pleural effusions
            Spontaneous pneumothorax
            Bronchopleural fistula
            Pleural fibrosis
            Pleural thickening
    • Information from [1, 93].

  • Table 4. Diagnostic criteria for allergic Aspergillus sinusitis [186, 189]
    Sinusitis of one or more paranasal sinus on radiography
    Necrosed amorphous tissue along with oedematous polyps infiltrated with eosinophils on histopathological evaluation of material from the sinus
    Demonstration of fungal elements in nasal discharge or in material obtained at the time of surgery by stain or culture
    Absence of diabetes, previous or subsequent immunodeficiency disease, and treatment with immunosuppressive drugs
    Absence of invasive fungal disease at the time of diagnosis or subsequently
    Other features
        Peripheral blood eosinophilia
        Type I and type III cutaneous hypersensitivity to Aspergillus
        Precipitating antibodies to Aspergillus antigens
        Elevated total, as well as Aspergillus-specific, IgE levels
        Characteristic computed tomography appearances
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Allergic aspergillosis of the respiratory tract
Ashok Shah, Chandramani Panjabi
European Respiratory Review Mar 2014, 23 (131) 8-29; DOI: 10.1183/09059180.00007413

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Allergic aspergillosis of the respiratory tract
Ashok Shah, Chandramani Panjabi
European Respiratory Review Mar 2014, 23 (131) 8-29; DOI: 10.1183/09059180.00007413
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    • Aspergillus-induced asthma
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