Diagnosis and treatment of allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is an underdiagnosed pulmona ry disorder in asthmatic patients and patients with cystic fibrosis. Its cl inical and diagnostic manifestations arise from an allergic response to mul tiple antigens expressed by fungi, most commonly Aspergillus fumigatus, col onizing the bronchial mucus. The clinical course is one of recurrent exacer bations characterized by chest infiltrates evident on chest x-ray films and associated with cough, wheeze, and sputum production that usually respond to oral corticosteroid treatment. Specific immunologic and radiologic marke rs of disease include elevation of the total serum IgE levels, presence of aspergillus IgE antibodies, and the occurrence of central bronchiectasis. L ongterm treatment with corticosteroids is often required for effective mana gement. The adverse effects of chronic corticosteroid use have led to attem pts at treatment with antifungal agents such as itraconazole. Itraconazole has been reported anecdotally to be effective, and evidence for its effecti veness in randomized trials is still accruing. Consideration should be give n to its use as a corticosteroid-sparing agent or for treatment of patients in whom corticosteroid response is poor. The natural history and prognosis of ABPA are not well characterized but may be complicated by progression t o bronchiectasis and pulmonary fibrosis. If ABPA is diagnosed and treated b efore the development of bronchiectasis and fibrosis, these complications m ay be prevented.