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bronchopulmonary
aspergillosis (ABPA)
Dr Ritesh Agarwal MD, DM
FACP, FCCP, FAPSR, FRCP(Glasg)
Associate Professor
Dept. of Pulmonary Medicine
Postgraduate Institute of Medical Education and Research
Chandigarh, India
Chandigarh
Agenda
Epidemiology of ABPA (in asthma)
Community prevalence of ABPA
Prevalence in secondary care cohorts
Prevalence in tertiary care cohorts
Global (and Indian) burden of ABPA
Peculiarities in the Indian ABPA cohort
ABPA
Hypersensitivity pulmonary disorder caused by immune
responses against Aspergillus fumigatus colonizing the
tracheobronchial tree of patients with asthma (and cystic
fibrosis)
little or no tissue invasion by the organism
First description
UK - Hinson KFW et al- [Thorax 1952; 7: 317-33]
US - Patterson R et al- [Univ Mich Med Cent J 1968; 34: 8-11]
India - Shah JR et al- [J Assoc Physicians India 1971; 19: 835-41]
New criteria
Terminology
Aspergillus sensitization
Clinical presentation
Although most patients with ABPA are diagnosed in the
third or fourth decade of life, there is no specific age or
gender predilection for its occurrence
Even children and the elderly may be afflicted
Familial occurrence has been documented in up to 5% of
cases
Community prevalence
Remains unknown because of lack of population-based
studies
The only population based data available is for
Aspergillus sensitization (NHANES, United States)
Prevalence of Aspergillus sensitization was found to be
6.4% using A.fumigatus specific IgE levels
This data is for the general population, however we want
similar data for asthmatic patients in the general
population
Year
Place
Benatar et al.
1980
Donnelly et al.
1991
Dublin, Ireland
Eaton et al.
2000
Al-Mobeireek et al.
Ma et al.
Total*
Total
No. with
asthmatics ABPA(M)
500
13 (2.6%)
1390
14 (1.0%)
Auckland, N Zealand
255
13 (5.1%)
2001
264
07 (2.7%)
2011
Beijing, China
200
05 (2.5%)
2609
52 (2.6%)
*random effects
model
Less than 2%
2-5%
>5%
Tertiary care
Study
Country
Type of study
Prevalence of ABPA in
asthma (n/N)
88/273
UK
Retrospective
US
Prospective
1/53
UK
Prospective
5/46
India
Retrospective
17/367
India
Prospective
18/200
US
Prospective
12/42
SL
Prospective
8/134
NZ
Prospective
9/35
India
Prospective
32/200
Maurya et al (2005)
India
Prospective
8/105
India
Prospective
155/755
India
Prospective
18/244
Agarwal R, et al. Int J Tuberc Lung Dis
Tertiary care
Prevalence of ABPA in asthma
Our experience
Active screening of asthmatics
997 asthmatics screened with Aspergillus skin test
Aspergillus sensitization - 378 (38%) patients
ABPA - 209 patients (21%)
ABPA without bronchiectasis (serologic ABPA) - 47
(22.5%) patients
ABPA with bronchiectasis - 162 (77.5%) patients
Burden of SAFS
Burden in India
Total population (2011 Indian census)
1,210,569,573
838,218,964
27,661,226
ABPA prevalence
0.70%
193,629
2.50%
691,531
5%
1,383,061
SAFS: 968,143
In Peer Review
Epidemiologic
peculiarities in the
Indian ABPA cohort
High-attenuation mucus
(HAM)
Pathognomonic finding of
ABPA
Uncommonly described
from other centers - Seen in
almost 20% of our patients
Could be recognition bias or
could really represent a
different spectrum of ABPA
Patients with HAM have
severer immunological
findings compared to other
patients and are prone for
relapses
ABPA in COPD
In India, ABPA has been identified in conditions other
than asthma and cystic fibrosis
ABPA in COPD
In a study of 200 consecutive COPD patients (and 100
healthy controls)
Aspergillus sensitization was found in 17 (8.5%) patients
with COPD
Two (1.0%) COPD patients fulfilled the criteria for
diagnosis of ABPA
Aspergillus
unsensitized
asthma (n=103)
50 (48.5)
05 (4-7)
Aspergillus
sensitized
asthma (n=99)
45 (45.5)
05 (5.7)
ABPA
(n=101)
P
value
66 (66)*
06 (5-7)
0.007
0.48
17 (16.5)
22 (21.4)
43 (41.7)
20 (19.4)
94 (91.3)
49 (47.6)
16 (15.5)
30 (29.2)
10 (9.7)
09 (9.2)
25 (25.8)
65 (65.7)*
18 (18.2)
88 (88.9)
48 (48.5)
08 (8.1)
25 (25.3)
09 (9.1)
09 (8.9)
29 (28.7)
54 (53.5)
28 (27.7)
95 (94.1)
58 (57.4)
13 (12.9)
34 (33.7)
19 (18.8)
0.32
0.48
0.003
0.20
0.43
0.3
0.56
0.43
0.07
Genetic predisposition
Innate immunity
Surfactant protein A2 gene
polymorphisms
Mannose-binding lectin gene
polymorphisms
Toll-like receptor 9 gene
polymorphisms
Adaptive immunity
Interleukin 10 promoter
polymorphisms
Interleukin 15 polymorphisms
Tumor necrosis factor-
polymorphisms
Transforming growth factor-
polymorphisms
HLA associations
Others
Genetic predisposition
Innate immunity
Surfactant protein A2 gene
polymorphisms
Mannose-binding lectin gene
polymorphisms
Toll-like receptor 9 gene
polymorphisms
Adaptive immunity
Interleukin 10 promoter
polymorphisms
Interleukin 15 polymorphisms
HLA associations
Others
Summary
ABPA has a global presence, significant burden and is far
more common than previously thought
The community prevalence is not known but the
prevalence is secondary care is about 2.5%
Need for community data, which is difficult to obtain
Data from primary care cohort should be obtained that
would serve as a surrogate for community prevalence
Thank you