European Journal of Cardiovascular Medicine

Allergic Bronchopulmonary Aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus species, commonly affecting individuals with asthma or cystic fibrosis (1). The main characteristic features of ABPA are frequent exacerbation of asthma, bilateral pulmonary infiltrates, bronchiectasis, and eosinophilia. The clinical presentation of the disease may vary but the most common symptoms are productive cough, wheezing and haemoptysis. The diagnosis of ABPA involves clinical, radiological, and serological findings.  importance of early diagnosis and treatment is essential as it can significantly alter the disease course of the disease and prevent its long-term complications. This report discusses a case of ABPA in a patient with a history of poorly controlled asthma. Long-term sequelae of this disease are mostly due to the delay in diagnosis and undertreatment which can result in worsening of the lung function secondary to pulmonary fibrosis, bronchiectasis with chronic mucus production (2). The incidence of ABPA is 1%-2% in asthmatic patients and 1%-7.8% in patients with cystic fibrosis (3).

A 31-year-old female with a known history of poorly controlled bronchial asthma presented to the clinic with complaints of a productive cough, which had been associated with bloody sputum, and progressive shortness of breath for the past week. The patient denied any history of fever, chest pain, or significant weight loss. She also had no notable family history of respiratory diseases or atopy, except for a mild history of hay fever.

On physical examination, the patient was alert and oriented, with no signs of cyanosis or clubbing. Respiratory examination revealed bilateral wheezing with a prolonged expiratory phase. Her vitals were stable, and no signs of respiratory distress were noted at the time of the visit. Initial laboratory investigations, including complete blood count (CBC), C-reactive protein (CRP), renal function tests, and liver function tests, were all within normal limits. Sputum cultures for acid-fast bacilli (AFB) were negative on three separate occasions. A chest X-ray revealed bilateral large nodular, fluffy shadows in both upper lobes, which prompted further imaging

Figure 1: Chest Xray showing fluffy nodular shadows and branching opacities in both upper lobes

A computed tomography (CT) scan of the chest demonstrated dilatation of segmental and subsegmental bronchi, particularly involving the anterior and posterior segments of the right upper lobe and the apical posterior segment of the left upper lobe. The dilated bronchi exhibited internal areas of iso to hyper attenuation, consistent with mucoid impaction. Additionally, tiny nodular shadows with a "tree-in-bud" appearance were noted on the peripheral aspects of the dilated bronchi, indicative of airway inflammation and fungal involvement.

Figure 2: CT chest showing dilatation of segmental and subsegmental bronchi with iso to hyper attenuated areas within them with no enhancement on post contrast study suggestive of mucous impaction

Serologic testing revealed a markedly elevated total IgE level of 6758 IU/mL (normal range: 0-100 IU/mL), which is highly suggestive of an allergic response. The allergen specific IGE levels to Aspergillus Fumigatus were positive at 3.10 (positive-more than 0.1). Bronchoscopy revealed a fungal ball in the posterior segment of the right upper lobe bronchus, further supporting the diagnosis of ABPA.

Figure 3: Bronchoscopy-showing fungal ball in the posterior segment of the upper lobe bronchus

Figure 4: Endobronchial cells and histiocytes mixed with squamous epithelial cells and PAS positive hyphae.

The clinical presentation, elevated total IgE, characteristic radiological findings, and bronchoscopy findings of a fungal ball were all consistent with a diagnosis of Allergic Bronchopulmonary Aspergillosis (ABPA) in this patient with poorly controlled asthma. Patient was started on prednisolone 40mg once daily and itraconazole 200mg twice daily and advised to follow up for regular monitoring.

ABPA is a complex immune-mediated disorder caused by hypersensitivity to Aspergillus species, primarily Aspergillus fumigatus. The pathogenesis of ABPA involves exaggerated response to the fungus and occurs most commonly in patients with asthma or cystic fibrosis (1). In the case of our patient, the prolonged exposure to Aspergillus antigens in the setting of poorly controlled asthma likely contributed to the development of ABPA.

The symptoms of ABPA are often non-specific and there occurs a considerable overlap with the predisposing lung condition. Up to one third of patients with ABPA are usually asymptomatic and are diagnosed on routine testing (4).  The most common symptoms associated with ABPA are chronic productive cough and wheezing. The other associated symptoms are fever, chest pain, weight loss, hemoptysis, night sweats (5). The other characteristic symptom is expectoration of yellowish-green lumps of mucus which can be present in half of the cases (1). In the initial stages of the disease the chest X ray can be normal.

The diagnosis of ABPA is based on a combination of clinical, serological criteria, including elevated total IgE levels, peripheral eosinophilia, positive skin tests for Aspergillus antigens, and characteristic radiological findings such as impaction of mucous and central bronchiectasis. In this patient, the elevated total IgE levels and "tree-in-bud" appearance on CT, along with the presence of a fungal ball on bronchoscopy, were all diagnostic of ABPA. Early diagnosis and careful treatment of this condition is crucial to prevent the progression of the disease and prevent its complications. The timely diagnosis also reduces the unnecessary use of antibiotics (6,7).

The treatment of ABPA typically involves antifungal therapy (e.g., itraconazole) in conjunction with corticosteroids to control the inflammatory response. The aim of treatment in ABPA is to suppress the hyperimmune inflammatory response and decrease the mycological load. This can be achieved by using  glucocorticoids and antifungal agents (4,8). In patients with acute ABPA, prednisolone is commonly administered as a single oral agent for a total duration of three to five months. The dose of prednisolone is 0.5 mg/kg every day for two weeks, then on alternate days for eight weeks, followed by a 5 mg tapering every two weeks (9). If patient gets frequent exacerbations once on steroids or has worsening of lung function tests or becomes steroid dependant, then antifungal therapy could be added (9,10). In our patient, treatment was initiated with systemic corticosteroids to address the acute inflammatory symptoms and itraconazole was added to control fungal proliferation. Regular follow-up was advised to monitor the patient's response to therapy, manage asthma control, and prevent further complications such as bronchiectasis or pulmonary fibrosis.

This case highlights the importance of recognizing Allergic Bronchopulmonary Aspergillosis in patients with poorly controlled asthma presenting with atypical symptoms such as hemoptysis and shortness of breath. Early diagnosis, based on clinical, radiological, and serological findings, is crucial for effective management and prevention of long-term complications. Clinicians should maintain a high index of suspicion for ABPA, especially in asthma patients with suboptimal disease control or recurrent respiratory exacerbations.

Financial Disclosure

None to declare.

Conflict Of Interest

There is no conflict of interest.

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