Aspergillosis--clinical aspects.

Allergic bronchopulmonary aspergillosis (ABPA) is much more common than originally suspected, can have its onset in childhood and remain undiagnosed for years or decades, at which time it presents in a patient with end-stage fibrotic lung disease. In other patients, ABPA may cause a finite number of roentgenographic lesions and not be associated with chronic sputum production or widespread bronchiectasis. Clinical symptoms range from the patient being asymptomatic with a new roentgenographic infiltrate being suspected only by a sharp elevation of total serum IgE to wheezing dyspnea or status asthmaticus. Serologic assays that are of major value in diagnosis of ABPA include elevation of total serum IgE--not all of which is directed against Aspergillus fumigatus, precipitating antibodies to A. fumigatus--unless the patient is in remission, and elevated serum IgE-A. fumigatus and IgG-A. fumigatus compared to serum from patients with asthma with immediate cutaneous reactivity to A. fumigatus but without evidence of ABPA. Five stages have been identified which reflect the time of recognition of ABPA and disease activity. They are Acute, Remission, Recurrent Exacerbation, Corticosteroid-Dependent Asthma, and Fibrotic. Stage I (Acute) patients have the classic clinical, serologic, and radiologic features of ABPA. Stage II (Remission) occurs after prednisone has resulted in resolution of the chest infiltrate and can be tapered and discontinued for 6 months without new infiltrates. Stage III (Exacerbation) occurs when a new roentgenographic infiltrate occurs associated with elevation of total serum IgE. Stage IV (Corticosteroid-Dependent Asthma) is present when repeated attempts to discontinue prednisone results in severe wheezing that cannot be prevented with other therapy. Some Stage IV patients continue to develop new ABPA infiltrates. Stage V (Fibrotic) patients have irreversible obstructive and restrictive pulmonary function abnormalities and may present or progress to respiratory failure and death.