Severe asthma with fungal sensitisation - SAFS

Do you have asthma that constantly flares up resulting in hospital visits?

If you are tested and found to be sensitive to fungi you may have SAFS.

Your doctor may not have heard of this condition or may not be convinced it exists. This is quite normal for a newly proposed cause of illness and only time will convince everyone it exists but it has been the subject of several double blinded clinical trials now and so evidence is mounting up. Print this page and show it to your doctor if you are concerned that you may have SAFS.

Patients with SAFS have troublesome asthma. They are adult male or females, with a mean age at diagnosis of ~50 years. Their pulmonary function measured by FEV1 or peak flow varies from 20-120% predicted, depending on how well their disease is controlled.

Presentation

Many have significant nasal symptoms with runny nose, sneezing and hayfever- like symptoms. They do not produce plugs of sputum, like ABPA patients do, although CT scans may show some mucous in airways. Eosinophilia is common. Most are completely dependent on high dose inhaled corticosteroids, with intermittent courses of oral steroids required for exacerbations, and some on continuous oral steroids. Chronic persistent asthma symptoms which are poorly controlled by multiple medications is a common feature for SAFS. Admission to hospital for asthma exacerbations is also common.

The criteria for defining SAFS are

  • Severe asthma (British Thoracic Society step 4 or worse)
  • Exclusion of ABPA ( total IgE <1000 IU/mL)
  • Evidence of sensitisation to one or more fungi, by skin prick test or RAST test

While some patients are sensitised to many fungi, the majority only react to one of two fungi. The commonest fungi that patients are sensitised to areA. fumigatus and C. albicans, with A. alternata, Trichopyton spp., Cladosporium herbarum, Penicillium chrysogenum and Botrytis cinerea. Skin test results are often not concordant with RAST results. RAST titres (to A. fumigatus) are much lower than titres in patients with ABPA.

Treatment

Patients with SAFS are usually on multiple medications. Long-term inhaled and frequent courses of oral corticosteroids, usually control the patients worst symptoms, but have well known adverse events. These patients are usually already taking either short or long-acting beta-2 agonists, or leukotriene antagonists with some benefit. 

Antifungal therapy with itraconazole (200mg orally, twice daily) is beneficial in having a major effect on pulmonary and nasal symptoms. (Therapeutic drug monitoring is advised for itraconazole to optimize exposure to itraconazole, which may require switching between capsules and oral solution, and sometimes raising or lowering the dose). Fluconazole may be beneficial in those sensitised to Trichophyton spp. The required duration of antifungal therapy is uncertain.