ABPA - Allergic Broncho-Pulmonary Aspergillosis

This is a condition where a patient develops an allergy to the spores of Aspergillus moulds. Predominantly it affects asthma patients but also cystic fibrosis and bronchiectasis patients. 

Allergic Broncho-Pulmonary Aspergillosis is a condition for which there is as yet no complete cure, so it is managed using steroids and antifungals in order to avoid any lung damage. The fungus takes up residence in the lungs and grows in the air spaces deep within. The fungus does not invade the lung tissue itself (it is non-invasive) but sets up a permanent source for irritation and allergic reaction.

Sufferers of ABPA find anywhere that has increased levels of airborne mould spores can trigger severe asthmatic reactions - e.g. compost heaps, damp buildings and even the outside air in some places at particular times of the year. Avoiding over-exposure - staying indoors or using an N95/FFP2 facemask may be advisable when this is a problem for you.

Diagnosis

There are eight criteria that have been suggested as indicative of ABPA.

  • Episodic wheezing (asthma)
  • Eosinophilia (increase in the number of certain white blood cells which fight disease)
  • Immediate skin test reactivity to Aspergillus antigens
  • Precipitating (IgG) antibodies to Aspergillus
  • Elevated total IgE
  • Elevated Aspergillus-specific IgE
  • Central bronchiectasis (widening of the airways)
  • History of pulmonary infiltrates (seen on X-ray)

If a patient has all eight of the above, diagnosis is certain.
If a patient has seven, diagnosis for ABPA is highly likely.

If the patient has asthma, eosinophilia and a history of infiltrates then ABPA should be considered as possible and the other tests can be done to attempt to confirm.

If the patient has fewer than seven of the above diagnosis becomes less sure. If a quick answer is needed or preferred and if the health of the patient allows then biopsy provides a very good way of deciding the diagnosis

Diagnosis definitions

Diagnosis for Cystic Fibrosis is a little different.

Treatment

Treatment consists of long term use of steroids (e.g. prednisolone) to reduce inflammation and lung damage. There are several potential difficulties with the use of steroid drugs for long periods but their use is vital to prevent the disease progressing.

We can now often reduce the amount of steroids taken by ABPA patients by giving the patient an antifungal medication such as itraconazole (e.g. Sporanox but there are now several brandnames). This seems to keep the fungus under control and some people can stop taking steroids completely for periods of time.

Another way to reduce the need for steroids is to reduce the inflammation. This is still experimental treatment but a new drug called anti-IgE (omalizumab) has been shown to be effective in a single patient study. This drug works by directly inhibiting a component of the immune system known as IgE. One of the functions of IgE is to promote inflammation and in this case it is permanently switched on by the aspergillosis infection, so the inflammation is permanently present and causes scarring (IgE would normally be switched off after a few days). Inhibiting IgE with omalizumab reduces inflammation and thus reduces the need for steroids.

It is known that many asthmatics have fungal allergy problems, a high proportion of these having ABPA, some possibly undiagnosed. The number of those diagnosed with asthma is growing constantly.

Young people with Cystic Fibrosis sometimes also suffer from ABPA, imposing further complications in their treatment.

Sufferers from the genetic disorder Chronic Granulomatous Disorder (CGD) may also be prone to developing Aspergillus infections.

Prognosis

There is no current cure for ABPA, but management of the inflammation and scarring using itraconazole and steroids usually succeeds in stabilising the symptoms for many years.

ABPA can very rarely progress to CCPA.

This is a relatively 'young' illness (first reported in 1952) with a long period of infection so it takes time for the long term results of improvements in care to become apparent. Identification of a fungal element in other severe asthmas suggests ABPA may well be much more common that was thought. ABPA is starting to lose its image of a rare and unusual infection and hopefully that will lead to increased awareness and improved management of the disease.

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Further information

The Aspergillus Website has pages intended for general reading on ABPA here.

Two interviews with patients, one with ABPA and another with an aspergilloma and lung aspergillosis, who discuss their condition can be seen here.

There is an article on ABPA in the Treatment Section of the Aspergillus Website. It is intended for readers who have some professional understanding of medicine but everyone could get something out of it. 

Read the article on treatment for ABPA.
More images
 

Compost Heaps

All handling of rotting vegetable matter should be done with care to avoid breathing in the clouds of spores that can be released when disturbing compost or soil. A facemask might be advisable if contact cannot be avoided.

Commercial Composting

The UK Health and Safety Executive have produced a document for workers exposed to the (large scale ) composting activities now used to manage compostable domestic waste. More...

Damp Buildings

All sources of damp in any building should be removed and any wet or damp materials removed or cleaned. More...

Cystic Fibrosis (CF)

Cystic Fibrosis causes severe clogging up of the lungs of its sufferers with thick sticky mucus that is difficult to remove. This and other factors makes the lungs vulnerable to infections including aspergillosis. CF sufferers have a higher risk of developing ABPA compared with the general populations (up to 11% CF sufferers become infected). More...

Chronic Granulomatous Disorder

People with CGD are less able to fight off infection and so are prone to infections including ABPA. There is an active charity in the UK supporting these people called the Chronic Granulomatous Research Trust and a Non-profit in the US called the Chronic Granulomatous Disease Association.

Face Masks

Most face masks on sale will NOT filter aspergillus spores out of the air you are breathing. The spores are extremely small (2-3 microns) and will pass easily through cheap paper masks. The European Union and the USA have set specific guidelines for grades of filters that will filter out spores. More...

Outside Air

The amount of fungal debris found in the outside air varies widely. Examination of databases that contain information on fungal spores found in the outside air in the UK show levels varying from virtually nothing up to 80000 spores per cubic metre. There are similar reports in the USA. In the UK we generally find that spores levels can be high up until the first frosts of winter.
Numbers of spores in the air are known to correlate with asthma.

Air travel warning

Severely asthmatic people can encounter difficulties travelling by air due to reduced cabin air pressure. Read these guidelines to ensure you will be ok.

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