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3 abpa talk
- 1. ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA) ANAS ZARMOUH(CONSULTANT IN GENERAL & RESPIRATORY MEDICINE) GLOBAL ASTHMA DAY - TRIPOLI 15 MAY 2018
- 2. OUTLINE • Background • Pathogenesis •Aspergillus lung disease • Diagnosis and work up • CT appearances • ABPA and SAFS • Treatment and follow up • Summary
- 3. BACKGROUND • ABPA iscaused by hypersensitivity (type I and III) reaction to Aspergillus • Aspergillus fumigatus (usually) is a ubiquitous fungus • Prevalence 1-2% of asthmatics. Upto 8% of CF patients.
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- 7. WHEN TO LOOKFOR ABPA? • Difficult to treat asthma • Step 4 & step 5 • Work up for chronic cough • Finding of bronchiectasis on CT
- 8. FEATURES AND DIAGNOSIS •Long h/o asthma • peripheral eosinophils • total IgE • specific IgE to Aspergillus • RAST IgE Aspergillus • Skin prick test to Aspergillus • Flitting consolidations on CXR • Central bronchiectasis on CT
- 9. DIFFERENTIAL DIAGNOSIS • Severeasthma with fungal sensitization • Churg-Strauss syndrome • Eosinophilic pneumonitis • Loeffler’s syndrome (ascariasis)
- 10. ABPA VS SAFS ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS •Very high total IgE • Very high specific Asp. IgE titres • Mostly due to Asp. Fumigatus • Prominent mucus plugging on CT • Itraconazole use more established SEVERE ASTHMA WITH FUNGAL SENSITISATION • Mildly elevated IgE (<1000) • Mildly elevated Specific Asp. IgE titre • Could be due to any fungus • No mucus plugging • Controversial role of Itraconazole
- 11. PROPOSED CLASSIFICATION OFABPA 1) ABPA-S Only seropositive without bronchiectasis on CT 2) ABPA-CP With central bronchiectasis
- 12. ABPA & CTFEATURES • All non-specific, but suggestive • Cystic, saccular or varicose dilated airways • Mostly central, not always • Thickened bronchial walls • Mucus plugging and bronchocoele formation • Features of airtrapping, tree-in-bud changes, collapse, cavities and lost of
- 13. TREATMENT • Manage asasthma with inhaler therapy • High dose ICS/LABA + LAMA +/- aminophylline • Long-term oral steroids • Prednisolone 30mg 1x1 2 months • Prednisolone 15mg 1x1 2 months • Prednisolone 7.5mg 1x1 long term (manipulate dose of stability with patient) • Stomach and bone protection with patient counselling • Adjunct anti-fungal • Itraconazole 200mg (or Voriconazole) 1x2 for 4 months (liver and interaction problems) • Anti-IgE • Could be trialled, but not enough literature to support routine use • Surgery • Raretly needed
- 14. FOLLOW UP ANDPROGNOSIS • All ABPA patient should be under routine follow up in the Chest Clinic • Total IgE check every 3 months • Guides OCS tapering or predicts relapse • Monitor spirometry, mMRC, sputum surveillance (pseudomonas & NTM), DEXA scan, blood sugar. • QOL and mortality: No data, but usually similar to patient with severe asthma
- 15. SUMMARY • Consider ABPAin chronic cough, severe asthma and bronchiectasis • CT is not diagnostic, but very useful • All patients should be under routine follow up in chest clinics • Treat exacerbations with longer courses of steroids and add Itraconazole for steroid sparing effect • Sputum surveillance and detection of Pseudomonas colonization affects disease progression and prognosis
- 16. REFERENCES • Murray_and_Nadel's_Textbook_of_Respiratory_Medicine v2011 4thedition. • Oxford handbook of respiratory medicine 2005 1st edition • Aspergillus & aspergillosis website (www.aspergillus.org.uk)
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