Journal List > Asia Pac Allergy > v.8(3) > 1148394

Asano, Kamei, and Hebisawa: Allergic bronchopulmonary mycosis – pathophysiology, histology, diagnosis, and treatment

Abstract

Allergic bronchopulmonary mycosis (ABPM) develops mainly in patients with asthma or cystic fibrosis via types I and III hypersensitivity reactions to filamentous fungi. Aspergillus spp., especially Aspergillus fumigatus, is the major causative fungus because of its small conidia, thermophilic hyphae, and ability to secrete serine proteases. The cardinal histological feature of ABPM is allergic (eosinophilic) mucin-harboring hyphae in the bronchi, for which the formation of extracellular DNA trap cell death (ETosis) of eosinophils induced by viable fungi is essential. Clinically, ABPM is characterized by peripheral blood eosinophilia, increased IgE levels in the serum, IgE and IgG antibodies specific for fungi, and characteristic radiographic findings; however, there are substantial differences in the clinical features of this disease between East and South Asian populations. Systemic corticosteroids and/or antifungal drugs effectively control acute diseases, but recurrences are quite common, and development of novel treatments are warranted to avoid adverse effects and emergence of drug-resistance due to prolonged treatment with corticosteroids and/or antifungal drugs.

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Fig. 1.
Histology of allergic (eosinophilic) mucin in the bronchi. Mucus plugs packed in the bronchi of surgically-resected lungs from a patient with allergic bronchopulmonary mycosis demonstrate a fir tree-like structure (A: H&E, x5), which contain many eosinophils, Charcot-Leyden crystals, and fibrin exudates (B: H&E, x40). (C) Hyphae of fungi are sparsely found in mucus plugs (Grocott staining, x40).
apa-8-e24f1.tif
Table 1.
Clinical characteristics of allergic bronchopulmonary aspergillosis (ABPA) in East and South Asia
Characteristic East Asia South Asia
Japan Korea China India
Study
Author [reference number] Tanimoto [39] Ishiguro [36] Oguma [7] Kim [37] Ye [40] Zhang [41] Behera [34] Chakrabarti [35] Prasad [38] Agarwal [6] Agarwal [33]
Publication year 2015 2016 2018 2012 2009 2017 1994 2002 2009 2010 2018
No. of cases 53 42 358 10 57 77 35 89 42 234 131
Age (yr) 57 57 64 63 41 42 34 36 31 34 37
Women 42% 57% 20% 42% 51% 60% 39% 36% 47% 47%
Asthma 79% 67% 81% 100% 96% 94% 80% 100% 100% 100%
Duration between onset of asthma and ABPA (yr) 31 14 15 11 12 12 6 12
Peripheral blood eosinophil counts (/µL) 580 1,075 1,198 847 1,271
Serum IgE levels (IU/mL) 1,170 1,913 927 5,015 10,540
Serum IgE levels > 1,000 IU/mL 81% 68% 50% 71% 100%
Specific IgE or immediate skin reaction to 100% 96% 100% 100% 89% 51% 82% 98% 100% 95%
Aspergillus antigen
Precipitins for Aspergillus antigen 77% 73% 57% 77% 72% 100% 83% 50%
Culture-positive for Aspergillus spp. 60% 59% 38% 63% 69%
Radiographic findings
Pulmonary opacities 100% 88% 20% 56% 79% 43% 95% 66%
Central bronchiectasis 98% 89% 80% 44% 81% 71% 69% 100% 77% 93%
High attenuation mucus 41% 21% 41%
Table 2.
Comparison of diagnostic criteria
Diagnostic criteria Rosenberg-Patterson 1977 Greenberger-Patterson 1986 ISHAM 2013
Asthma or cystic fibrosis
Peripheral blood eosinophilia  
Increased levels of IgE in serum
Immediate skin reaction to Aspergillus antigen
Specific IgE to Aspergillus fumigatus  
Specific IgG to Aspergillus fumigatus  
Precipitin to Aspergillus fumigatus  
Pulmonary opacities  
Central bronchiectasis
Positive sputum culture of Aspergillus fumigatus    
Expectoration of brownish mucous plugs    
Arthus-type skin reaction to Aspergillus antigen    

Closed circles are mandatory components. In International Society for Human Animal Mycology (ISHAM) criteria, 2 out of 3 components (open circles) should also be fulfilled. Triangles are secondary components, further supporting the diagnosis of allergic bronchopulmonary aspergillosis.

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