Abosulte eosinophil count : 0.966 K

1. Abosulte eosinophil count : 0.966 K/ul ( 0.04- 0.4 K/ul ) TFT � Normal LFT � Normal ANA Screen : Negative HIV Emergency Screen : Negative HBsAg : Negative Anti HCV : Negative

2. Peripheral Blood Smear : Normocytic Normochromic blood picture with Eosinophilia WIDAL Test : Negative Blood C/S : No Growth Urine C/S : No Growth

3. CXR

4. CT CHEST WITH CONTRAST

5. CT CHEST WITH CONTRAST Varicoid & Cystic bronchiectatic changes involving both upper lobes ( Left > Right ) , Right middle lobe, superior segment of both lower lobes, proximal bronchi of basal segments. Mucoid impaction in proximal lingular bronchi

6. BAL Gram Smear : negative AFB Smear : negative Fungal Smear : negative C/S : Pseudomonas AFB C/S : Awaited Fungal C/S : Awaited Cytology : No Atypical cells / Fungi

7. SKIN TEST FOR ASPERGILLUS : POSITIVE Serum Aspergillus IgG : + Serum Aspergillus IgM : +

8. DIAGNOSIS PROBABLE ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS BRONCHIAL ASTHMA

9. Aspergillus may cause a broad spectrum of disease in the human host, ranging from hypersensitivity reactions to direct angioinvasion. Aspergillus primarily affects the lungs, causing 4 main syndromes, including Allergic Bronchopulmonary Aspergillosis (ABPA), Chronic Necrotizing Aspergillus Pneumonia or Chronic Necrotizing Pulmonary Aspergillosis Aspergilloma, Invasive Aspergillosis

10. However, in patients who are severely immunocompromised Aspergillus may hematogenously disseminate beyond the lung potentially causing : Endophthalmitis Endocarditis Abscesses in the myocardium, kidney, liver, spleen, soft tissue, and bone Aspergillus is second to Candida species as a cause of fungal endocarditis. Aspergillus -related endocarditis and wound infections occur in the context of cardiac surgery

11. Allergic bronchopulmonary aspergillosis (ABPA) is caused by a hypersensitivity reaction�to the fungus and most commonly occurs in those with asthma. Saprophytic aspergillosis, or aspergilloma, is the most common form, which is noninvasive and involves colonization of preexisting cavities. Chronic necrotizing aspergillosis, also called airway-invasive or semi-invasive aspergillosis, is a chronic cavitary pneumonic illness that often affects patients with preexisting chronic lung disease. Angioinvasive aspergillosis affects immunocompromised patients and is often fatal.

12. ABPA ABPA is a hypersensitivity reaction to A.fumigatus colonization of the tracheobronchial tree and occurs in conjunction with asthma and cystic fibrosis (CF). Allergic fungal sinusitis may also occur alone or with ABPA. Bronchocentric granulomatosis and Malt worker's lung are 2 hypersensitivity lung diseases that are caused by Aspergillus species, but they are rare

13. Microscopic slide of lung tissue. This image shows broad hyphae, which branch at acute angles.

14. In ABPA, Branching finger-in-glove tubular opacities in the left lower lobe due to mucus plugging of ectatic bronchi

15. Central Bronchiectasis in ABPA 

16. DIAGNOSTIC CRITERIA FOR ABPAABPA WITH ASTHMA ( without CysticFibrosis ) Asthma Immediate cutaneous reaction to Aspergillus fumigatus Total serum Ig E > 1000 ng / ml Elevated serum specific Aspergillus IgE, IgG Serum precipitins to Aspergillus antigen Peripheral blood eosinophilia Transient or fixed pulmonary infiltrates Proximal bronchiectasis

17. When a patient with asthma does not have bronchiectasis the following criteria are : high total serum IgE levels immediate cutaneous reaction to Aspergillus, elevated Aspergillus-specific IgE (or IgG) levels precipitating Aspergillus antibodies in serum In other cases, particularly in the absence of systemic corticosteroids : elevated blood eosinophil counts, marked increases in precipitating Aspergillus antibodies pulmonary infiltrate allow ABPA diagnosis

18. ABPA In Patients with Cystic Fibrosis Clinical deterioration (coughing, wheezing, increased sputum production, exercise intolerance and decrease in pulmonary function) Immediate hypersensitivity to A. fumigatus (positive skin test or IgE response) Total serum IgE concentration >1000 kUI/l Precipitating antibodies to A. fumigatus Abnormal chest roentgenogram (infiltrate, plugs or unexplained changes compared to previous chest X-ray). The recommendation is that Cystic fibrosis patients should be screened for ABPA from 6 years of age, once a year / in response to ABPA.

19. CLINICAL FEATURES Onset can be in childhood but is more common in young adults. Most of the patients have other allergic manifestations like rhinitis, conjunctivitis & atopic dermatitis The ABPA onset occurs at the time of, or more frequently after, asthma onset and is usually associated with the transformation of mild asthma into corticosteroid-dependent asthma with some symptoms

20. symptoms like �.. malaise, fever (body temperatures reaching 38.5C), Presence of sputum plugs and purulent sputum, coughing or chest pain hemoptysis

21. Clinically in to 5 stages

22. DIFFERENTIAL DIAGNOSIS Inadequately controlled asthma Pulmonary tuberculosis in high prevalent areas Bacterial, viral, fungal pneumonia Eosinophilic pneumonia, Bronchocentric granulomatosis Churg-Strauss syndrome Hypersensitivity pneumonitis

23. TREATMENT Early detection and prompt treatment of ABPA exacerbations, so as to prevent or minimize bronchiectasis Manage associated asthma or irreversible obstructive and restrictive lung disease Exclude others having ABPA in family, and To identify potential environmental source of incremented fungus

24. Corticosteroids remain the early treatment options and are cornerstone of treatment. Aggressive treatment of early stages, may halt progression to stage of fibrosis.

25. Corticosteroids The recommended dose is Prednisolone 0.5 mg/kg/day for the first 2 weeks, Followed by a progressive decrease in dose over the next 6�8 weeks Long-term systemic corticosteroid therapy is not recommended If the patient has no new exacerbation within 6 months, he is judged to be in remission (stage II).

26. Stage IV patients have severe asthma, which is corticosteroid-dependent. In these cases, the minimal dose required to stabilize the patient must be identified The extent of the bronchial destruction in Stage V patients makes the prognosis poor. In addition, these patients suffer from recurrent infections (the majority of which involve Pseudomonas) and respiratory insufficiency with limited exercise tolerance. Treatment with corticosteroids is generally proposed, but is poorly efficient.

27. Antifungals Several antifungal agents (e.g. amphotericin B, ketoconazole,clotrimazole, nystatin and natamycin) have been proposed as treatments for ABPA. However, no significant beneficial effects were observed when these drug treatments were tested and in several cases these agents were responsible for severe adverse effects.

28. In contrast, the new orally administered antifungal agent, Itraconazole, appears to be an effective adjunctive therapy for ABPA.

29. Preliminary retrospective clinical study comparing the outcome of a 1-year itraconazole treatment with that of 2-year therapy with the normal treatment of corticosteroids alone was done. The number of exacerbations was lower for the itraconazole treated group than for the group treated with corticosteroids alone. Corticosteroid daily requirements decreased from 22 to 6.5 mg/day, although the dose required differed substantially between patients.

30. ASPERGILLOMA A fungal ball (mycetoma) that develops in a preexisting cavity in the lung parenchyma. Underlying causes of the cavitary disease may include treated tuberculosis or other necrotizing infection, sarcoidosis, CF, and emphysematous bullae. The ball of fungus may move within the cavity but does not invade the cavity wall It may cause hemoptysis.

31. ASPERGILLOMA

32. CNPA A subacute process usually found in patients with some degree of immunosuppression, most commonly that associated with underlying lung disease, alcoholism, or long-term corticosteroid therapy. As it is uncommon, CNPA often remains unrecognized for weeks or months and can cause a progressive cavitary pulmonary infiltrate.

33. Chronic, cavitating, upper lobe consolidation in patient with long-standing fibrosing alveolitis; this finding is consistent with chronic necrotizing aspergillosis. Aspergillus fumigatus was cultured from the sputum and percutaneous aspiration samples