Evaluation of the Clinicoradiological Profile in Cases of Allergic Bronchopulmonary Aspergillosis: An Original Research

ABSTRACT

Introduction:

A complicated hypersensitive reaction to inhaled fungal antigens results in allergic bronchopulmonary aspergillosis (ABPA), an immunologic pulmonary disease. ABPA complicates nearly 2% of instances of persistent asthma as well as nearly 10% of chronic cases of steroid-dependent asthma, and it occurs most frequently in immunocompetent patients. The purpose of the current research was to analyze the radiological and clinical features of the participants as well as the serological association of ABPA.

Materials and Methods:

From April 2020 to April 2021, a retrospective investigation was conducted. The study included patients based on the International Society for Human and Animal Mycology’s criteria for ABPA confirmation. Analysis was done on the demographic information and pathological and radiological test results of the patients. The patients’ pre-bronchodilator and post-bronchodilator spirometry was compared, and asthmatic control was estimated.

Results:

A total of 50 patients were investigated at in this study. Demographic findings indicated young subjects and aa female predominance. Cough was the most prevalent symptom in 84% of patients. Asthma of the bronchi was a risk factor for all of the patients. The mean serum immunoglobulin E level and the mean absolute eosinophil count were 533 cells/L and 2269 UI/mL, respectively. Spirometry results from the study’s participants indicated an obstructive pattern in about 80% of cases. The most typical radiological abnormality observed was bronchiectasis, followed by parenchymal opacities.

Conclusion:

In conclusion, when treating asthma that is challenging to control, the diagnosis of ABPA must be taken into account. Delay in diagnosis might result in declining lung function, worsening asthma control, possibly irreversible alterations, greater treatment costs, and declined quality of life.

INTRODUCTION

A pulmonary immunologic condition known as allergic bronchopulmonary aspergillosis (ABPA) is brought on by an intolerance to Aspergillus which is a type of fungal species. Clinically speaking, the patient has chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis.[1] Although the frequency of this condition in the general population is unclear, people with cystic fibrosis and asthma are almost always affected.[2] Because the development of bronchiectasis is linked to worse outcomes, this disorder needs to be identified before it manifests. As these patients are usually asymptomatic, when treating asthmatics, one should always consider ABPA as a potential danger[2-7] This emphasizes the necessity of routine screening for ABPA in all patients with asthma and cystic fibrosis. The current research was carried out to investigate the serological association of ABPA as well as the clinical and radiological profiles of the patients.

MATERIALS AND METHODS

The current study was piloted retrospectively from the department records that were collected at a tertiary center between April 2020 and April 2021 with the proper approval from our institute’s institutional review board. Basic information and pathological and radiological test results of the patients. The patients’ pre -bronchodilator and post -bronchodilator spirometry was compared , and asthmatic control was estimated. Only adult subjects were analyzed for the study and included two genders. The study included patients based on the “International Society for Human and Animal Mycology’s criteria for ABPA” confirmation. The data that were collected were analyzed as the descriptive statistics and no comparisons were made.

RESULTS

The subjects were in the young adult age groups with the mean age of 35.6 years. The women were predominant with men to women ratio of 10:15 as given in Table 1.

Table 1.

Demographics and clinical features

Demographics	Findings
Age	35.6 years
Male: Female	10:15
Clinical feature	Number of subjects
Smokers	10
Anorexia	20
Breathlessness	34
Cough	42
Diabetes	4
Expectoration	15
Fever	14
GERD	10
Hemoptysis	4
Tuberculosis history	18
Hypertension	2
Predisposing condition (asthma/cystic fibrosis)	50/0
Psychiatric problems	2
Hematology	Values
Absolute eosinophil count	533
IgE	2269 IU/mL
Specific IgE for A. fumigatus (mean)	8.93
Specific IgG for A. fumigatus (mean)	39.0

For the distribution of the subjects based on the clinical features, it was observed that smokers [n = 10], anorexia [n = 20], breathlessness [n = 34], cough [n = 42], diabetes [n = 4], expectoration [n = 15], fever [n = 14], GERD [n = 10], hemoptysis [n = 4], tuberculosis history [n = 18], hypertension [n = 2], predisposing condition (asthma/cystic fibrosis) [n = 50/0], and psychiatric problems [n = 2] as given in Table 1.

Hematological findings showed that the absolute eosinophil count was 533; IgE-2269 IU/mL; specific IgE for Aspergillus fumigatus (mean)-8.93; specific IgG for A. fumigatus (mean)-39.0 as given in Table 1.

When the subjects were evaluated for the spirometry, it was observed that the forced expiratory volume pre- and post-bronchodilator was 67 and 73, respectively, while the forced vital capacity pre- and post-bronchodilator was 71 and 85, respectively. The distribution of the subjects in the asthmatic controls was seen as to be not well-controlled in majority of the subjects (n = 25). When the radiological findings of the chest X-ray were observed, majority subjects depicted the opacities and bronchiectasis. HRCTC thorax corroborated the findings of the chest x-ray as given in Table 2.

Table 2.

Number of the subjects for the spirometry, level of asthma control, and radiological findings

Spirometry	Value
FVC pre-bronchodilator*	75
FVC post-bronchodilator*	81
FEV1 pre-bronchodilator*	67
FEV1 post-bronchodilator*	73
Obstructive pattern	40
Restrictive pattern	8
Level of asthma control
Control	Number of subjects
Well controlled	11
Not well controlled	25
Very poorly controlled	14
Radiology	Number of subjects
Chest Xray
Normal	10
Opacities	12
Consolidation	8
Effusion	2
Bronchiectasis	14
Cavity	8
Mucus plugging	2
HRCT thorax
Normal	4
Opacities	14
Consolidation	10
Effusion	4
Bronchiectasis	14
Cavity	8
Mucus plugging	4

FEV₁=Forced expiratory volume in 1 second, FVC=Forced vital capacity *(mean percentage predicted)

DISCUSSION

Chest radiography findings in ABPA can be roughly divided into transitory and fixed categories.[4] Exacerbations of ABPA are marked by the recognizable transient opacities, whereas late stages are marked by fixed abnormalities. Currently, ABPA prefers the imaging modality of CT thorax. Bronchitis is the most typical chest CT finding. The diagnosis of ABPA is thought to be characterized by central bronchiectasis, albeit bronchiectasis can also be peripheral.[5-7]

A complicated hypersensitive reaction to inhaled fungal antigens results in ABPA, a disease.[8] ABPA complicates 1% of instances of persistent asthma and approximately 10% of cases of chronic asthma (steroid-dependent), and it occurs most frequently in immunocompetent patients.[8] Type 1, 3, and 4 immune reactions are thought to have contributed to the complicated immunologic reaction to aspergillus colonization of the airways throughout time.[4]

In contrast to other research on ABPA, where the mean age of patients was over 50 years old, the majority of the subjects in the current study were young. In contrast to earlier investigations, more women than men were diagnosed with ABPA.[5-7,9,10] In line with the high prevalence of bronchial asthma and low prevalence of cystic fibrosis in India, every patient in the study had bronchial asthma, and no one had cystic fibrosis. About 40% of the study’s patients had a history of tuberculosis in the past.

Due to the fact that all of the study participants had bronchial asthma, the majority of patients (80%) on pulmonary function testing had an obstructive pattern. Even nevertheless, 16% of the research participants’ lung function tests revealed a restrictive pattern even though their prior pulmonary function tests had revealed an obstructive pattern with reversibility. This can be a result of asthma getting worse.

Bronchitis, which was found in seven patients, was the most prevalent radiographic abnormality reported in ABPA patients. Seven individuals had opacities, and five of them had consolidation. In the study, the mucus plugging was observed in four patients only.

Each participant in the study had experienced symptoms for at least four weeks. Additionally, all of the study participants had previously used oral steroids and/or broad-spectrum antibiotics to treat asthma flare-ups. Only four patients (or roughly 17%) had asthma that was well-controlled when it was assessed using the ACT. Despite spirometry suggesting minor obstruction in 12 of the remaining 19 patients (approximately 83%) with asthma, the asthma was not adequately managed in these patients.

When managing difficult-to-control asthma, the likelihood of concomitant ABPA must be considered and carefully investigated. Delay in diagnosis might result in poorer quality of life, deteriorating lung function, possibly irreversible alterations, lower asthma control, and higher treatment costs.

The clinic-radiological profile, changes in response to treatment, prognosis, and responsiveness to treatment were not evaluated due to the retrospective nature of the study. The study included fewer participants because it was conducted during the COVID-19 pandemic, and patients who tested positive for the virus were not included.

CONCLUSION

When treating asthma that is difficult to control, the diagnosis of ABPA must be taken into account. Lack of control over asthma, deteriorating lung function, poor quality of life, and higher treatment costs can all result from a delayed diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.