Allergic bronchopulmonary aspergillosis (ABPA)

Question 1

allergic bronchopulmonary aspergillosis

Answer 1

immunological pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus

seen with asthmatics and CF pts from chronic bronchial colonization

Question 2

symptoms of ABPA

Answer 2

low grade fever, wheezing, bronchial hyperreactivity, hemoptysis, productive cough with brownish mucous plugs see mucoid impaction of the bronchi, eosinophilic pneumonia and bronchocentric granulomatosis

Question 3

what happens with repeated episodes of ABPA?

Answer 3

bronchiectasis and fibrosis

Question 4

what is seen on CT scan with ABPA

Answer 4

central bronchiectasis and mucus filled bronchi and fleeting pneumonias or see airway plugging

Question 5

Diagnosis of ABPA

Answer 5

if CT scan is suggestive of ABPA, get a skin prick test - if negative get a intradermal reactivity test to Aspergillus.

Next, needs an NEGATIVE intradermal reactivity to Aspergillus to remove it from differential.

Skin prick test will be positive for Aspergillus species antigen with a positive wheal and flare

On labs will see peripheral eosinophilia. If positive, need to get immunochemistry with serum total IgE>417 IU/ML

see serum antibodies to Aspergillus are positive.

Don’t need a bronchoscopy to diagnosis

Question 6

treatment of ABPA?

Answer 6

corticosteroids and itraconazole (1st line) and voriconazole (2nd line if intolerant) to help inflammation and control and prevent reversible damage

Question 7

what medications can cause eosinophilic pneumonia

Answer 7

sulfonamides,

ampicillin,

azithromycin,

anticonvulstants (phenytoin)

Question 8

Churg Strauss syndrome presentation

Answer 8

seen with asthma and presents with eosinophilia, mononeuropathy and polyneuropathy and transient pulmonary opacities

Question 9

aspergillus is

Answer 9

monomorphic fungus with septate hyphae branching at acute angles with fruiting bodies. ABPA- see hypersensitivity to aspergillus and so will see asthma or chronic bronchiectasis

Question 10

fevers, night sweats, chronic productive cough with occasional hemoptysis and wheezing that’s not responsive to inhalers can see exporation of dark brown mucus plugs

Answer 10

ABPA seen in cystic fibrosis or asthma pts seen at any age but most commonly at 30-40 yrs

Question 11

why is important to diagnose APBA sooner as opposed to later?

Answer 11

important to treat it because if left untreated can develop bronchiectasis. onset of bronchiectasis is associated with poor outcomes

Question 12

PFTs of APBA shows:

Answer 12

obstructive pattern early and mixed restrictive and obstructive pattern after bronchiectasis develops

Question 13

TO definitively rule out APBA need to get:

Answer 13

negative skin prick test for aspergillus.

Next, needs an NEGATIVE intradermal reactivity to Aspergillus to remove it from differential.

If there’s an immediate cutaneous hypersensitivity with skin prick it means there’s serum A. fumigatus species IgE antibodies

Question 14

Treatment of APBA is

Answer 14

itraconazole and steroids.

Question 15

symptoms of invasive pulmonary aspergillus are:

Answer 15

non specific and mimic bronchopenumonia, fever unresponsive to antibiotics, cough, sputum production and dyspnea.

See pleuritic chest pain (due to vascular invasion leading to thrombosis and causing pulmonary infarcts) and hemoptysis-which is mild.

most common causes of hemoptysis in neutropenic pts - aspergillus

Question 16

invasive pulmonary aspergillosis imaging:

Answer 16

CXR may NOT detect early stage disease (small nodules)

CT: single and multiple nodules with or without cavitations and see “halo sign” (nodules surrounded by ground glass infiltrations)

diagnosis is suggested by culture and histology

Enzyme linked immunosorbent assay on serum or BAL can detect galactomannan antigen (present Aspergillius cell walls) espeically in pts hematological malignancies.

Question 17

Treatment of invasive aspergillus infection

Answer 17

voriconazole - g_old standard as a primary therapy for invasive aspergillosis_.

more effective than amphotericin B as initial therapy for IPA and associated with significantly improved survival (75% vs 58% respectively) in a randomized trial.

Do not give high dose steroids for invasive aspergillosis.