Allergic bronchopulmonary aspergillosis

A 38 year old male was diagnosed to have allergic bronchopulmonary aspergillosis which responded remarkably to prednisolone therapy.     

Allergic bronchopulmonary aspergillosis in a patient with no symptoms of asthma until after bronchial lavage

An asymptomatic 56-year-old man was admitted to our hospital because of an abnormal shadow on a chest X-ray film. Allergic bronchopulmonary aspergillosis was diagnosed on the basis of five findings: eosinophilia, immediate skin reactivity to Aspergillus antigen, the presence of precipitating antibodies against Aspergillus antigen, a high concentration of IgE in serum, and central bronchiectasis. He had no symptoms of asthma at the time of diagnosis, but did a few days after he underwent bronchial lavage. We speculate that the asthma attack was related to the bronchial Lavage as follows: First, drainage of mucus plugs by bronchial lavage may have exposed the bronchial epithelium, which had already been sensitized, to aspergillus antigens. Second, the scattered antigen may have dose-dependently stimulated the bronchi. Third, the infection may have increased bronchial responsiveness to the antigen. Symptoms of bronchial asthma are not necessary for the diagnosis of allergic bronchopulmonary aspergillosis.     

A fatal case of ovarian hyperstimulation syndrome with cerebral infarction

BACKGROUND: A 76-year-old man developed allergic bronchopulmonary aspergillosis initially presenting with cough variant asthma. Symptoms worsened after exposure to ground mulch which was an identifiable source of Aspergillus fumigatus. Symptoms improved after corticosteroids and avoidance measures were instituted. OBJECTIVE: To report a case of allergic bronchopulmonary aspergillosis presenting as cough variant asthma with identifiable source of Aspergillus fumigatus. METHODS: Single case report. Serum precipitating antibodies against Aspergillus fumigatus were tested using gel diffusion techniques. Total IgE, specific IgE, and IgG indices were measured by ELISA. Cutaneous reactivity to Aspergillus fumigatus was also tested. RESULTS: Skin test and serum precipitating antibodies to Aspergillus fumigatus were positive. Precipitins were also detected between Aspergillus fumigatus and the mulch. Total serum IgE was 538 IU/mL (1290 ng/mL) which declined to 228 IU/mL (544 ng/mL) after corticosteroid therapy. IgE index = 1.10 and IgG index = 2.86. CONCLUSION: Allergic bronchopulmonary aspergillosis can present as cough variant asthma. Identification of exacerbating factors such as sources of Aspergillus fumigatus are important in management.     

Functionalized 1,3-teraryls as a new class of hepatoprotectants. Part V

A 29-year-old man was admitted to the hospital because of a high fever and dyspnea. He had a history of bronchial asthma and had had a bullectomy of the right lung at 15 years of age. He had visited a family physician because of fever and non productive coughing. Medications had no effect on his symptoms, and dyspnea developed. A chest X-ray film showed total collapse of the right lung, and he was referred to our hospital. Laboratory data showed eosinophilia and a high titer of IgE. Total obstruction of the right main stem bronchus by mucous plug was found during fiberoptic bronchoscopy. Aspergillus was detected by pathological examination of bronchial lavage fluid. Tests for aspergillus-specific IgE and IgG antibody were positive, as was immediate skin reactivity to Aspergillus. Allergic bronchopulmonary aspergillosis (ABPA) was diagnosed. Infusion and inhalation of a corticosteroid and fluconazole were effective; the symptoms resolved and X-ray findings improved. While migratory infiltration, proximal bronchiectasis and segmental or subsegmental atelectasis caused by a mucous plug are common X-ray findings in allergic bronchopulmonary aspergillosis, total collapse is rare.     

Severe small airways disease resistant to medical treatment in a child with cystic fibrosis

At the age of 12, a child with cystic fibrosis developed severe small airways obstruction of unknown aetiology, in the absence of significant bronchiectasis. He remained resistant to medical treatment until, following an exacerbation of allergic bronchopulmonary aspergillosis 18 months later, he responded to high dose oral steroids. He now remains steroid-dependent, and suffering from multiple side-effects. Possible aetiology and further therapeutic strategies are discussed.     

Chronic bronchopulmonary aspergillosis in a horse with Cushing's syndrome

An atypical case of chronic equine bronchopulmonary aspergillosis with an unusual hyphal morphology was diagnosed in a horse with Cushing's syndrome. Because of the hyphal localization in chronic ectatic bronchi and bronchioles, and juxtabronchiolar processes, the observed type of aspergillosis is similar to 'saprophytic bronchopulmonary aspergillosis' or 'semi-invasive pulmonary aspergillosis' in humans. The aetiological diagnosis of aspergillosis was accomplished by the application of a panel of monospecific polyclonal and monoclonal antibodies in immunohistochemical techniques.     

Allergic bronchopulmonary mycosis caused by Pseudallescheria boydii

Two cases of allergic bronchopulmonary pseudallescheriosis (ABPP) are described. These are the first cases of this allergic bronchopulmonary mycosis (ABPM) reported in which the clinical and serologic criteria are described. The first case was in a patient with mild asthma, and it resolved spontaneously after expectoration of a mucous plug. The second was in a patient with recurrent allergic bronchopulmonary aspergillosis with an exacerbation of ABPM caused by Pseudallescheria boydii. The total serum IgE, IgG, and IgE antibodies against P. boydii and the clinical picture well define ABPP. This diagnosis may be important to recognize in order to prevent a progression of the patient's lung disease.     

Allergic bronchopulmonary aspergillosis effectively treated with itraconazole

A 23-year-old man with bronchial asthma presented with fever, cough, and sputum. A chest X-ray examination showed pulmonary infiltrations in the left upper and lower lung fields with central bronchiectasis. Although his temperature came down with antibiotics, pulmonary infiltrations persisted with cough and sputum. Following bronchoscopy and an allergological examination, the patient was given a diagnosis of allergic bronchopulmonary aspergillosis (ABPA) based on Rosenberg's criteria, including peripheral blood eosinophilia, a high serum IgE level, immediate skin reaction to Aspergillus antigen, positive precipitating antibodies, and Aspergillus fumigatus in sputum. The patient was treated with itraconazole instead of corticosteroids. His respiratory symptoms, eosinophilia, and pulmonary infiltration then disappeared, and his IgE serum level gradually decreased. An antifungal agent alone was effective in treating this ABPA patient.     

Immunodominant peptide epitopes of allergen, Asp f 1 from the fungus Aspergillus fumigatus

Aspergillus fumigatus ribotoxin Asp f 1 is a major allergen with IgE binding activity to serum of a majority of patients with allergic bronchopulmonary aspergillosis (ABPA). The IgE binding epitopes or the T-cell stimulatory peptides of this molecule have not been studied. In the present investigation, we have synthesized linear decapeptides spanning the whole molecule of Asp f 1 and analyzed their IgE binding properties. We have also synthesized peptides based on their possible T-cell stimulatory properties and studied the stimulation of peripheral blood mononuclear cells from ABPA patients and normal controls. Several peptides demonstrated distinct IgE antibody binding response against sera from ABPA patients and proliferative response against peripheral blood mononuclear cells from the patients. From the results, it can be concluded that the carboxy-terminal region of Asp f 1 representing amino acid residues 115-149 involved in both humoral and cell mediated immunoresponses in ABPA.     

Contact allergy to topical corticosteroids and systemic contact dermatitis from prednisolone with tolerance of triamcinolone

We report the case of a 27-year-old female who had an allergic contact dermatitis to topical corticosteroids belonging to the corticosteroid groups A and D. Upon oral treatment with prednisolone a disseminated exanthema began within 24 h. Patch tests revealed sensitization to corticosteroids of group A, C and D, including prednisolone-21-acetate and betamethasone valerate, but not of group B corticosteroids such as triamcinolone. After intradermal testing of corticosteroids the exanthema flared again and the patient was treated with oral triamcinolone, with rapid improvement of her symptoms. A literature review revealed that exanthematous reactions after systemic treatment with corticosteroids have been rarely reported. Since corticosteroids are essential emergency drugs, a safe corticosteroid should be identified for such patients. Patch and intradermal tests may be used for that purpose.     

Cytokine messenger RNA expression by donor-specific cytotoxic T-cell clones after allogeneic heart transplantation

BACKGROUND: Aspergillosis is an uncommon yet serious opportunistic infection in patients with AIDS. It has been extensively reported in HIV-infected adult patients. To our knowledge there are no studies that describe the epidemiology, clinical manifestations and outcome of aspergillosis in a large HIV-infected pediatric population. METHODS: We reviewed the records of all 473 HIV-infected children followed in the Pediatric Branch of the National Cancer Institute for 9 years from 1987 through 1995 for the presence of Aspergillus infection. RESULTS: Seven (1.5%) patients developed invasive aspergillosis during the study period. All patients had low CD4 counts reflecting severe immunosuppression. Sustained neutropenia (> 7 days) or corticosteroid therapy as a predisposing factor for invasive aspergillosis was encountered in only two patients (28%). Invasive pulmonary aspergillosis developed in five patients and cutaneous aspergillosis in two. The most common presenting features in patients with pulmonary aspergillosis were fever, cough and dyspnea. Patients with cutaneous aspergillosis were diagnosed during life and successfully treated with amphotericin B and surgery, whereas diagnosis of pulmonary aspergillosis was made clinically in only one patient. CONCLUSIONS: Aspergillosis is an uncommon but highly lethal opportunistic infection in HIV-infected children. Invasive pulmonary aspergillosis should be considered in the differential diagnosis in febrile, HIV-infected children with persistent pulmonary infiltrates.     

The major late promoter and bipartite leader sequence of fowl adenovirus

Invasive pulmonary aspergillosis in immunocompromised patients (ICP) is the second most frequent opportunistic fungal infection. The causative organism includes 16 species of Aspergillus, of which A. fumigatus dominates the ubiquitous incidence of invasive or allergic broncho-pulmonary aspergillosis (ABPA). The definitive diagnosis of invasive aspergillosis is difficult. We have analyzed 24 strains of A. fumigatus recovered from ICP using the RAPD technique. The profiles generated with the 20 primers tested were mostly unique. These results may have a profound impact on the management of aspergillosis, especially in the ICP.     

Intranasal azelastine. A review of its efficacy in the management of allergic rhinitis

Azelastine, a phthalazinone compound, is a second generation histamine H1 receptor antagonist which has shown clinical efficacy in relieving the symptoms of allergic rhinitis when administered as either an oral or intranasal formulation. It is thought to improve both the early and late phase symptoms of rhinitis through a combination of antihistaminic, antiallergic and anti-inflammatory mechanisms. Symptom improvements are evident as early as 30 minutes, after intranasal administration of azelastine [2 puffs per nostril (0.56mg)] and are apparent for up to 12 hours in patients with seasonal allergic rhinitis (SAR). The effect on nasal blockage is variable: in some studies objective and/or subjective assessment showed a reduction in blockage, whereas in other studies there was no improvement. Intranasal azelastine 1 puff per nostril twice daily is generally as effective as standard doses of other antihistamine agents including intranasal levocabastine and oral cetirizine, ebastine, loratadine and terfenadine at reducing the overall symptoms of rhinitis. The relative efficacies of azelastine and intranasal corticosteroids (beclomethasone and budesonide) remain unclear. However, overall, the corticosteroids tended to improve rhinitis symptoms to a greater extent than the antihistamine. Azelastine was well tolerated in clinical trials and postmarketing surveys. The most frequently reported adverse events were bitter taste, application site irritation and rhinitis. The incidence of sedation did not differ significantly between azelastine and placebo recipients and preliminary report showed cardiovascular parameters were not significantly altered in patients with perennial allergic rhinitis (PAR). Conclusion: Twice-daily intranasal azelastine offers an effective and well tolerated alternative to other antihistamine agents currently recommended for the symptomatic relief of mild to severe SAR and PAR in adults and children (aged > or = 12 years in the US; aged > or = 6 years in some European countries including the UK). The rapid onset, confined topical activity and reduced sedation demonstrated by the intranasal formulation of azelastine may offer an advantage over other antihistamine agents, although this has yet to be confirmed.     

Ceftriaxone (Rocefin) in the treatment of bronchopulmonary infections]

Ceftriaxone, cephalosporin of the third generation, was given to 40 adults admitted to hospital for bronchopulmonary infections. Pneumonia and aggravation of chronic bronchitis were diagnosed in 27 and 13 patients, respectively. The drug was given in a single daily dose 1-2 g intravenously or intramuscularly. Mean duration of the treatment course was 6.13 days. High efficacy of the antibiotic ceftriaxone was observed in 38(95%) patients. One woman failed the treatment. She had pneumonia following polychemotherapy for advanced breast cancer. The drug tolerance was good. Only one allergic reaction occurred. The study of the sensitivity of 333 strains of the bacteria isolated from the sputum of 235 pulmonological patients showed that the absolute majority of the strains (98%) of both gram-positive and gram-negative microorganisms are suppressed by ceftriaxone. Thus, the conclusion is made on efficacy of ceftriaxone against bronchopulmonary infections. The drug is applicable both in hospitals and outpatiently.     

Immunological characterization of Asp f 2, a major allergen from Aspergillus fumigatus associated with allergic bronchopulmonary aspergillosis

The 37-kDa recombinant protein Asp f 2, encoding an allergen of Aspergillus fumigatus, was expressed in a prokaryotic expression system and immunologically evaluated for its functional and structural properties. The open reading frame for a 310-amino-acid-long protein was shown to encode a signal peptide of 31 amino acids. A native 37-kDa culture filtrate protein and a 55-kDa mycelial glycoprotein (gp55) exhibited complete N-terminal sequence homology to Asp f 2. A GenBank search for homologous proteins revealed 60 and 44% sequence homologies to the cytosolic protein ASPND1 from Aspergillus nidulans and fibrinogen binding protein from Candida albicans, respectively. The glycosylation sites and cysteine molecules are conserved in all the three proteins. The extracellular matrix protein laminin showed a dose-dependent interaction with Asp f 2. This protein, expressed as a major cell-associated protein within 24 h of in vitro fungal culture, comprises 20 to 40% of total fungal protein. Furthermore, both native and recombinant Asp f 2 exhibited specific immunoglobulin (IgE) binding with allergic bronchopulmonary aspergillosis (ABPA) and cystic fibrosis-ABPA patients, whereas A. fumigatus-sensitized allergic asthma and normal control subjects failed to show IgE binding with Asp f 2. These results indicate that Asp f 2 is a major allergen of A. fumigatus exhibiting IgE antibody binding with sera from patients with ABPA. The antigen should be explored further for its potential role in the differential diagnosis of A. fumigatus-associated allergic diseases.     

Itraconazole in the treatment of orbital aspergillosis

BACKGROUND: Sino-orbital aspergillosis is typically treated with surgical debridement and intravenous amphotericin B. Some authors have advocated intraorbital irrigation or injection of amphotericin B in specific cases. METHODS: An immunocompetent patient with recurrent sino-orbital aspergillosis is presented. After failing two attempts at traditional therapeutic modalities, treatment with oral itraconazole was initiated. RESULTS: The patient has had resolution of her sino-orbital disease without recurrence at 10 months of follow-up. CONCLUSION: In immunocompetent patients with orbital aspergillosis, itraconazole should be considered as a treatment option in patients who have recurrent or recalcitrant disease, or in those who cannot tolerate amphotericin B.     

Failed Nissen fundoplication in two patients who had persistent vomiting and eosinophilic esophagitis

The following report describes two patients who had chronic symptoms of gastroesophageal reflux and persistent histological esophagitis, despite aggressive medical antireflux therapy, who continued to have esophagitis and remained symptomatic post antireflux surgery (Nissen fundoplication). Both patients demonstrated a severe eosinophilic esophagitis with normal gastric and duodenal histology before and after surgery. Postoperatively, each received the diagnosis of allergic enteritis and both responded clinically and histologically to oral corticosteroids and an elemental diet.     

Chronic sinusitis: characterization of cellular influx and inflammatory mediators in sinus lavage fluid

Chronic sinusitis is a recurrent disorder commonly found in atopic individuals, yet few studies have explored the role of inflammatory mediators in sinusitis. Sinus lavage fluid from ten patients with chronic sinusitis obtained during endoscopic surgery was analyzed for total cell counts and then assayed for histamine, immunoreactive leukotriene C4/D4/E4 (LTC4/D4/E4), and prostaglandin D2 (PGD2). All ten patients had been unresponsive to medical treatment, including oral corticosteroids in most cases. High concentrations of histamine, LTC4/D4/E4 and PGD2 were found in sinus fluid and were comparable to levels seen in nasal secretions of allergic rhinitis patients following allergen challenge. In the sinus fluid, inflammatory cells were predominantly neutrophils with only low percentages of mast cells, basophils or eosinophils. On the basis of the histamine and PGD2 concentrations in sinus fluid, we conclude that mast cell/basophil activation does occur in chronic sinusitis and may contribute to the persistent inflammation present in sinusitis.     

Treatment of invasive aspergillosis: relation of early diagnosis and treatment to response

Aspergillus infections in patients with cancer are difficult to diagnose, and such diagnoses are frequently made at necropsy. Earlier therapy has been proposed to provide better response. We reviewed 17 consecutive patients with documented aspergillosis to determine the impact of earlier diagnosis and prompt treatment with amphotericin B. Sixteen had hematologic malignancies, and all had marked granulocytopenia. Six were diagnosed and treated within 96 h of the appearance of infiltrates. Three of these six had complete resolution of all signs and symptoms of aspergillus infection. The other three had a partial response to therapy despite continued granulocytopenia. All 11 patients in whom antifungal therapy was either delayed (six) or not given (five) for at least 2 weeks after the infiltrate was present diet with progressive aspergillosis aggressive diagnostic methods to establish the diagnosis of aspergillosis are warranted so that antifungal therapy can be started early, which may then be successful in resolving these potentially fatal infections.