Nepomuceno I B, Esrig S, Moss R B
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA.
Chest. 1999 Feb;115(2):364-70. doi: 10.1378/chest.115.2.364.
(1) To determine the relationship between IgE levels and the prevalence of allergic bronchopulmonary aspergillosis (ABPA) in cystic fibrosis (CF) patients, (2) to establish the usefulness of assessing atopy as an identifying risk factor for ABPA, (3) to evaluate the clinical course of patients receiving and not receiving itraconazole as reflected in oral steroid dose requirements and number of acute episodes of ABPA, and (4) to determine the role of acute episodes of ABPA in pulmonary exacerbations of CF.
Retrospective review of online clinical database and medical records.
CF clinic and inpatient services of Lucile Salter Packard Children's Hospital at Stanford.
One hundred seventy-two patients with CF for whom serial serum total IgE levels were measured over a 5-year study period, 1992 to 1996.
We reviewed records of patients followed up at the CF Center at Stanford who had serum total IgE measured between January 1, 1992, and December 31, 1996. Total IgE and Aspergillus fumigatus (Af) specific IgE antibodies were measured by commercial fluorometric solid-phase immunoassay. Precipitating antibodies to Af were measured by double immunodiffusion. Patients who were diagnosed as having ABPA were treated with itraconazole unless significant liver dysfunction was present. Oral steroid dosing requirements and acute episodes of ABPA for days with vs days without itraconazole were compared.
Serum total IgE was elevated (> 1 SD > geometric mean for age) in 51% of patients tested. IgE > 500 IU/mL, chosen as a screening cutoff for evaluating possible ABPA, was present in 19% of patients at some time during the study period. Atopy (defined as > or = 1 IU/mL IgE antibody to > or = 1 allergen) was present in 61% of 104 patients tested for specific allergen sensitization. ABPA was diagnosed in 16 patients (9%). ABPA occurred in 22% of atopic CF patients but only in 2% of nonatopic patients (p = 0.001). Six percent of pulmonary exacerbations requiring hospitalization were associated with acute episodes of ABPA. Over the study period, itraconazole use was associated with a reduced average daily oral steroid dose of 47% (p = 0.05) and a reduction in the number of acute ABPA episodes by 55% (p < 0.001).
Screening for atopy may be a cost-effective way to select CF patients for periodic monitoring with total serum IgE levels, since there is an increased risk of ABPA developing in atopic CF patients. Itraconazole treatment of ABPA is safe and associated with fewer acute episodes of ABPA despite reduction in average daily oral steroid dose.
（1）确定囊性纤维化（CF）患者中免疫球蛋白E（IgE）水平与变应性支气管肺曲霉病（ABPA）患病率之间的关系；（2）确定将特应性评估作为ABPA识别风险因素的有用性；（3）评估接受和未接受伊曲康唑治疗的患者的临床病程，这可通过口服类固醇剂量需求和ABPA急性发作次数反映出来；（4）确定ABPA急性发作在CF肺部加重中的作用。
对在线临床数据库和病历进行回顾性研究。
斯坦福大学露西尔·萨特·帕卡德儿童医院的CF诊所和住院服务部。
1992年至1996年的5年研究期间，对172例CF患者进行了系列血清总IgE水平检测。
我们回顾了1992年1月1日至1996年12月31日期间在斯坦福CF中心接受随访且检测了血清总IgE的患者记录。总IgE和烟曲霉（Af）特异性IgE抗体通过商业荧光固相免疫测定法进行检测。Af沉淀抗体通过双向免疫扩散法进行检测。被诊断为ABPA的患者接受伊曲康唑治疗，除非存在严重肝功能障碍。比较了接受和未接受伊曲康唑治疗的日子里口服类固醇剂量需求和ABPA急性发作次数。
51%接受检测的患者血清总IgE升高（>1个标准差>年龄的几何平均值）。在研究期间的某个时间，19%的患者IgE>500 IU/mL，这一数值被选作评估可能ABPA的筛查临界值。在104例接受特异性变应原致敏检测的患者中，61%存在特应性（定义为对≥1种变应原的IgE抗体≥1 IU/mL）。16例患者（9%）被诊断为ABPA。ABPA发生在22%的特应性CF患者中，但仅发生在2%的非特应性患者中（p = 0.001）。6%需要住院治疗的肺部加重与ABPA急性发作相关。在研究期间，使用伊曲康唑与平均每日口服类固醇剂量降低47%（p = 0.05）以及ABPA急性发作次数减少55%（p < 0.001）相关。
筛查特应性可能是一种经济有效的方法，用于选择CF患者进行血清总IgE水平的定期监测，因为特应性CF患者发生ABPA的风险增加。伊曲康唑治疗ABPA是安全的，且尽管平均每日口服类固醇剂量降低，但ABPA急性发作次数较少。
