Monsall Unit, Department of Infectious and Tropical Diseases, North Manchester General Hospital, Manchester, UK.
Semin Respir Crit Care Med. 2011 Dec;32(6):682-92. doi: 10.1055/s-0031-1295716. Epub 2011 Dec 13.
While allergic bronchopulmonary aspergillosis (ABPA) is well recognized as a fungal complication of asthma, severe asthma with fungal sensitization (SAFS) is not. In ABPA the total immunoglobulin E (IgE) is usually >1,000 IU/mL, whereas in SAFS it is <1,000 IU/mL, and either skin prick tests or fungus-specific IgE tests are positive. ABPA may present with any severity of asthma, and occasionally with no asthma or cystic fibrosis, the other common underlying disease. SAFS is a problem in patients with poorly controlled asthma and occasionally presents in the intensive care unit (ICU). Production of mucous plugs and coughing paroxysms is more common in ABPA. Certain underlying genetic defects seem to underpin these remarkable phenotypic differences. From a management perspective both ABPA and SAFS respond to both high doses of corticosteroids and oral antifungal agents, with ∼60% response rate in both ABPA and SAFS with itraconazole. In 50% of patients itraconazole boosts inhaled corticosteroid exposure, sometimes leading to cushingoid features. Second-line therapy data are scant, but we have shown that 70 to 80% of patients who tolerate either voriconazole or posaconazole also respond. Other useful therapies include nebulized hypertonic saline to aid expectoration of thick sputum and long-term azithromycin for its anti-inflammatory effect on the airways. Omaluzimab is useful in some patients with SAFS and occasionally in ABPA. Complications of ABPA include bronchiectasis, typically central in distribution, and chronic pulmonary aspergillosis. Most patients with ABPA and SAFS can be stabilized for long periods with inhaled corticosteroids and itraconazole or another antifungal agent. Novel immunotherapies are on the horizon.
虽然变应性支气管肺曲霉病（ABPA）是一种公认的哮喘真菌并发症，但严重哮喘伴真菌致敏（SAFS）则不然。在 ABPA 中，总免疫球蛋白 E（IgE）通常>1000IU/mL，而在 SAFS 中则<1000IU/mL，并且皮肤点刺试验或真菌特异性 IgE 试验均为阳性。ABPA 可能表现为任何严重程度的哮喘，偶尔也可能没有哮喘或囊性纤维化，这是另一种常见的潜在疾病。SAFS 是控制不佳的哮喘患者的一个问题，偶尔也会出现在重症监护病房（ICU）。ABPA 更常见黏液栓和咳嗽发作。某些潜在的遗传缺陷似乎为这些显著的表型差异提供了基础。从管理的角度来看，ABPA 和 SAFS 都对大剂量皮质类固醇和口服抗真菌药物有反应，伊曲康唑在 ABPA 和 SAFS 中的反应率约为 60%。在 50%的患者中，伊曲康唑会增加吸入皮质类固醇的暴露，有时会导致库欣样特征。二线治疗数据很少，但我们已经表明，70%到 80%耐受伏立康唑或泊沙康唑的患者也有反应。其他有用的治疗方法包括雾化高渗盐水以帮助咳出浓稠的痰液，以及长期使用阿奇霉素以发挥其对气道的抗炎作用。奥马鲁单抗对某些 SAFS 患者和偶尔的 ABPA 患者有用。ABPA 的并发症包括支气管扩张症，通常呈中央分布，以及慢性肺曲霉病。大多数 ABPA 和 SAFS 患者可以通过吸入皮质类固醇和伊曲康唑或另一种抗真菌药物长期稳定。新型免疫疗法正在出现。
