Allergic bronchopulmonary aspergillosis and other allergic mycoses. Part 3: Radiology, therapy, and special topics

Allergic bronchopulmonary aspergillosis (ABPA) presents a broad spectrum of radio-logic alterations. The most common changes in conventional chest radiography are fleeting pulmonary infiltrates. A viscous bronchial mucus of high density ("high attenuation mucus" = HAM) shows the highest diagnostic specificity and can be found approximately in 20% of cases by CT scans. A complete bronchial congestion due to secretion ("mucoid impaction") can lead to lobal atelectasis Central bronchiectases are very characteristic for ABPA, even though they are recently regarded as a complication, which can be avoided by early diagnosis and treatment. In case of lacking bronchiectasis the term serologic ABPA (ABPA-S) is used. Treating acute stages of ABPA systemic steroid therapy is so far the gold standard. Information on dosage and length of therapy differ sometimes considerably in the literature. Two recent studies showed however, that the azoles itraconazole and voriconazole lead to nearly similar effects. In future these could be valuable alternatives, in particular for patients with steroid side effects or contraindications against steroids (e.g. diabetes or osteoporosis). For therapy of chronic courses of ABPA recommendation for itraconazole additionally to a steroid already exists for a long time. Biologicals as well, in particular the anti-IgE agent omalizumab, proved to be successful in patients which didn't respond to steroids or had steroid side effects. An allergen-specific immunotherapy with the causative mould is not recommended. Non-drug measures focus on regular secretion mobilization with physical aids and respiratory therapy. Rarely a bronchoscopic extraction of the viscous mucus will be necessary. In any case allergen avoidance should be tried to establish, which can be optimally achieved with a respiratory rehab in a low allergen surrounding. In childhood ABPA is mainly associated with cystic fibrosis, but can also occur in bronchial asthma. Many studies point to a genetic disposition of ABPA. ABPA is frequently associated with disorders of the paranasal sinuses (e.g. allergic fungal sinusitis), so that with appropriate complaints an ENT specialist should be consulted.