Figures
- 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.
- 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.
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.
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.
High-resolution computed tomography of the thorax a) mediastinal window and b) corresponding section on the lung window showing high attenuation mucus impaction.
- Figure 6.
Computed tomography of the paranasal sinuses showing hyperdense lesions in the frontal, ethmoid and maxillary sinuses bilaterally, suggestive of inspissated secretions.
Tables
- 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
