Abbie Fairs

Fungi and allergic lower respiratory tract diseases

Asthma is a common disorder that in 2009 afflicted 8.2% of adults and children, 24.6 million persons, in the United States. In patients with moderate and severe persistent asthma, there is significantly increased morbidity, use of health care support, and health care costs. Epidemiologic studies in the United States and Europe have associated mold sensitivity, particularly to Alternaria alternata and Cladosporium herbarum, with the development, persistence, and severity of asthma. In addition, sensitivity to Aspergillus fumigatus has been associated with severe persistent asthma in adults. Allergic bronchopulmonary aspergillosis (ABPA) is caused by A fumigatus and is characterized by exacerbations of asthma, recurrent transient chest radiographic infiltrates, coughing up thick mucus plugs, peripheral and pulmonary eosinophilia, and increased total serum IgE and fungus-specific IgE levels, especially during exacerbation. The airways appear to be chronically or intermittently colonized by A fumigatus in patients with ABPA. ABPA is the most common form of allergic bronchopulmonary mycosis (ABPM); other fungi, including Candida, Penicillium, and Curvularia species, are implicated. The characteristics of ABPM include severe asthma, eosinophilia, markedly increased total IgE and specific IgE levels, bronchiectasis, and mold colonization of the airways. The term severe asthma associated with fungal sensitization (SAFS) has been coined to illustrate the high rate of fungal sensitivity in patients with persistent severe asthma and improvement with antifungal treatment. The immunopathology of ABPA, ABPM, and SAFS is incompletely understood. Genetic risks identified in patients with ABPA include HLA association and certain T(H)2-prominent and cystic fibrosis variants, but these have not been studied in patients with ABPM and SAFS. Oral corticosteroid and antifungal therapies appear to be partially successful in patients with ABPA. However, the role of antifungal and immunomodulating therapies in patients with ABPA, ABPM, and SAFS requires additional larger studies.

IgE Sensitization to Aspergillus fumigatus Is Associated with Reduced Lung Function in Asthma

RATIONALE The importance of Aspergillus fumigatus sensitization and colonization of the airways in patients with asthma is unclear. OBJECTIVES To define the relationship between the clinical and laboratory features of A. fumigatus-associated asthma. METHODS We studied 79 patients with asthma (89% classed as GINA 4 or 5) classified into 3 groups according to A. fumigatus sensitization: (1) IgE-sensitized (immediate cutaneous reactivity > 3 mm and/or IgE > 0.35 kU/L); (2) IgG-only-sensitized (IgG > 40 mg/L); and (3) nonsensitized. These were compared with 14 healthy control subjects. Sputum culture was focused toward detection of A. fumigatus and compared with clinical assessment data. MEASUREMENTS AND MAIN RESULTS A. fumigatus was cultured from 63% of IgE-sensitized patients with asthma (n = 40), 39% of IgG-only-sensitized patients with asthma (n = 13), 31% of nonsensitized patients with asthma (n = 26) and 7% of healthy control subjects (n = 14). Patients sensitized to A. fumigatus compared with nonsensitized patients with asthma had lower lung function (postbronchodilator FEV₁ % predicted, mean [SEM]: 68 [±5]% versus 88 [±5]%; P < 0.05), more bronchiectasis (68% versus 35%; P < 0.05), and more sputum neutrophils (median [interquartile range]: 80.9 [50.1-94.1]% versus 49.5 [21.2-71.4]%; P < 0.01). In a multilinear regression model, A. fumigatus-IgE sensitization and sputum neutrophil differential cell count were important predictors of lung function (P = 0.016), supported by culture of A. fumigatus (P = 0.046) and eosinophil differential cell count (P = 0.024). CONCLUSIONS A. fumigatus detection in sputum is associated with A. fumigatus-IgE sensitization, neutrophilic airway inflammation, and reduced lung function. This supports the concept that development of fixed airflow obstruction in asthma is consequent upon the damaging effects of airway colonization with A. fumigatus.

Aspergillus fumigatus during stable state and exacerbations of COPD

Bacteria are often isolated in stable chronic obstructive pulmonary disease (COPD). Whether fungi are also commonly present and associated with clinical and pathological features of disease is uncertain. We investigated the frequency of filamentous fungal culture and IgE sensitisation to Aspergillus fumigatus and the relationship to clinical outcomes in COPD subjects. COPD subjects were recruited to enter a 1-year observational study. Assessments of lung function, allergen testing and sputum analysis for inflammation, bacteria and fungus were undertaken in COPD subjects and healthy smoking and nonsmoking controls. Filamentous fungi were cultured at baseline in 49% (63 out of 128) of COPD subjects, of which 75% (47 out of 63) were A. fumigatus. Fungus was cultured in three out of 22 controls (two were A. fumigatus). The total sputum cell count and inhaled corticosteroid dosage were significantly increased in COPD patients with a positive filamentous fungal culture at baseline (p<0.05). Sensitisation to A. fumigatus was present in 13% of COPD subjects and was associated with worse lung function (forced expiratory volume in 1 s 39% predicted versus 51% predicted; p=0.01), but not related to filamentous fungal culture. A. fumigatus sensitisation is related to poor lung function. Positive filamentous fungal culture is a common feature of COPD. The clinical significance of this remains uncertain. A. fumigatus sensitisation links to poor COPD lung function; clinical significance of positive fungal culture is unclear http://ow.ly/qfr5q

Routine processing procedures for isolating filamentous fungi from respiratory sputum samples may underestimate fungal prevalence.

Colonization of the airways by filamentous fungi can occur in asthma, chronic obstructive pulmonary disease (COPD) and cystic fibrosis. A recent study found IgE sensitization to Aspergillus fumigatus to be associated with reduced lung function. Significantly higher rates of A. fumigatus were detected in sputum from asthmatics sensitized to this fungus compared to non-sensitized asthmatics. The rate of positive cultures was far higher than equivalent historical samples analysed by the local clinical laboratory following protocols recommended by the UK Health Protection Agency (HPA). This study compares the HPA procedure with our sputum processing method, whereby sputum plugs are separated from saliva and aliquots of approximately 150 mg are inoculated directly onto potato dextrose agar. A total of 55 sputum samples from 41 patients with COPD were analyzed, comparing fungal recovery of five dilutions of sputa on two media. Isolation of A. fumigatus in culture was significantly higher using the research approach compared to the HPA standard method for mycological investigations (P < 0.001). There was also a significant difference in the recovery rate of A. fumigatus (P < 0.05) between media. This highlights the need for a standardized approach to fungal detection which is more sensitive than the method recommended by the HPA

Effectiveness of voriconazole in the treatment of Aspergillus fumigatus–associated asthma (EVITA3 study)

BACKGROUND IgE sensitization to Aspergillus fumigatus and a positive sputum fungal culture result are common in patients with refractory asthma. It is not clear whether these patients would benefit from antifungal treatment. OBJECTIVES We sought to determine whether a 3-month course of voriconazole improved asthma-related outcomes in patients with asthma who are IgE sensitized to A fumigatus. METHODS Asthmatic patients who were IgE sensitized to A fumigatus with a history of at least 2 severe exacerbations in the previous 12 months were treated for 3 months with 200 mg of voriconazole twice daily, followed by observation for 9 months, in a double-blind, placebo-controlled, randomized design. Primary outcomes were improvement in quality of life at the end of the treatment period and a reduction in the number of severe exacerbations over the 12 months of the study. RESULTS Sixty-five patients were randomized. Fifty-nine patients started treatment (32 receiving voriconazole and 27 receiving placebo) and were included in an intention-to-treat analysis. Fifty-six patients took the full 3 months of medication. Between the voriconazole and placebo groups, there were no significant differences in the number of severe exacerbations (1.16 vs 1.41 per patient per year, respectively; mean difference, 0.25; 95% CI, 0.19-0.31), quality of life (change in Asthma Quality of Life Questionnaire score, 0.68 vs 0.88; mean difference between groups, 0.2; 95% CI, -0.05 to -0.11), or any of our secondary outcome measures. CONCLUSION We were unable to show a beneficial effect of 3 months of treatment with voriconazole in patients with moderate-to-severe asthma who were IgE sensitized to A fumigatus on either the rate of severe exacerbations, quality of life, or other markers of asthma control.

DNA analysis of outdoor air reveals a high degree of fungal diversity, temporal variability, and genera not seen by spore morphology.

Fungi are ubiquitous with many capable of causing disease by direct infection, toxicoses, or allergy. Fungal spores are present in outdoor air throughout the year, yet airborne diversity is poorly characterised. Airborne fungal spores are routinely counted by microscopy, enabling identification to genera at best. We generated traditional microscopic counts over a year, then used environmental sequencing techniques to assess and compare 3 d selected from the main fungal spore season. The days selected corresponded to one with a high quantity of spores unidentifiable by microscopy, and two representing dry and wet summer periods. Over 86 % of genera detected by sequencing were not routinely identifiable by microscopy. A high degree of temporal variability was detected, with the percentage of clones attributed to Basidiomycota or Ascomycota, and composition of genera within each phylum varying greatly between days. Throughout the year Basidiomycota spores were found at higher levels than Ascomycota, but levels fluctuated daily with Ascomycota comprising 11-84 % of total spores and Basidiomycota 7-81 %. No significant difference was found between the proportion of clones attributed to each morphological group detected by sequencing to that counted by microscopy (P = 0.477, 0.985, and 0.561). The majority of abundant genera detected by DNA analysis are not routinely identified by microscopy (>75 %). Of those, several are known human and plant pathogens, and may represent unrecognised aeroallergens.

Allergic fungal airway disease: pathophysiologic and diagnostic considerations.

Purpose of review Fungal spores are ubiquitously present in indoor and outdoor air. A number can act as aeroallergens in Immunoglobulin E (IgE)-sensitized individuals and some thermotolerant fungi germinate in the lung where they can cause a combined allergic and infective stimulus leading to a number of clinical presentations characterized by evidence of lung damage. We discuss which biomarkers are useful in helping to guide diagnosis, prognosis and treatment of allergic fungal airway disease (AFAD). Recent findings Diagnostic biomarkers, such as specific IgEs and fungal culture, for AFAD are limited by sensitivity, although this may be improved with novel agents such as specific IgEs to fungal components and quantitative PCR. Total IgE and hypereosinophilia are nonspecific and do not clearly relate to disease activity. High attenuation mucus and proximal bronchiectasis are specific, albeit insensitive markers of AFAD. Biomarkers that predict prognosis and treatment response are yet to be defined. Summary This review summarizes the fungi involved and the current debate regarding the diagnostic criteria to define fungal-associated lung disease. We advocate the phasing out of the term allergic bronchopulmonary aspergillosis and the use of a more inclusive term such as AFAD, together with a more liberal set of criteria based largely on IgE sensitization to thermotolerant fungi, which identifies those patients at risk of developing lung damage.

Isolation of Aspergillus fumigatus from sputum is associated with elevated airborne levels in homes of patients with asthma

Indoor bioaerosols, such as mold spores, have been associated with respiratory symptoms in patients with asthma; however, dose-response relationships and guidelines on acceptable levels are lacking. Furthermore, a causal link between mold exposure and respiratory infections or asthma remains to be established. The aim of this study was to determine indoor concentrations of Aspergillus fumigatus and a subset of clinically relevant fungi in homes of people with asthma, in relation to markers of airways colonization and sensitization. Air and dust samples were collected from the living room of 58 properties. Fungal concentrations were quantified using mold-specific quantitative PCR and compared with traditional microscopic analysis of air samples. Isolation of A. fumigatus from sputum was associated with higher airborne concentrations of the fungus in patient homes (P = 0.04), and a similar trend was shown with Aspergillus/Penicillium-type concentrations analyzed by microscopy (P = 0.058). No association was found between airborne levels of A. fumigatus and sensitization to this fungus, or dustborne levels of A. fumigatus and either isolation from sputum or sensitization. The results of this study suggest that the home environment should be considered as a potential source of fungal exposure, and elevated home levels may predispose people with asthma to airways colonization.

S90 Effectiveness of Voriconazole In the Treatment of Aspergillus fumigatus Associated Asthma

Background IgE sensitisation to Aspergillus fumigatus and a positive sputum fungal culture are common in refractory asthma. It is not clear whether these patients would benefit from anti-fungal treatment. Objectives To determine if a three-month course of voriconazole improved asthma related outcomes in people with asthma who are IgE sensitised to A. fumigatus. Methods Asthmatics IgE sensitised to A fumigatus with a history of at least two severe exacerbations in the previous twelve months were treated for three months with voriconazole two hundred milligrams twice daily, followed by observation for nine months, in a double blind, placebo controlled, randomised design. Primary outcomes were improvement in quality of life at the end of the treatment period and a reduction in the number of severe exacerbations over the twelve months of the study. Results 65 patients were randomised. 59 patients started treatment (32 voriconazole and 27 placebo) and were included in an intention to treat analysis. 56 patients took the full three months of medication. There was no significant difference in the number of severe exacerbations between the voriconazole and placebo groups (1.25 vs 1.52/patient/year; mean difference 0.27; 95% CI 0.24 to 0.31) respectively, quality of life (change in AQLQ 0.44 vs 0.35, mean difference between groups 0.08; 95% CI 0.07–0.09), or in any of our secondary outcome measures between the two groups. Conclusion We were unable to show a beneficial effect of three months treatment with voriconazole in people with moderate to severe asthma who were IgE sensitised to A fumigatus on either the rate of severe exacerbations, quality of life or other markers of asthma control. Abstract S90 Figure 1. References Fairs A, Agbetile J, Hargadon B, Bourne M, Monteiro WR, Brightling CE, et al. IgE sensitisation to Aspergillus fumigatus is associated with reduced lung function in asthma. Am J Respir Crit Care Med. 2010;182(11):1362–8.

S91 Aspergillus fumigatus sensitisation in patients with chronic obstructive pulmonary disease

Background Bacteria and viruses have been implicated in exacerbations of chronic obstructive pulmonary disease (COPD) and bacteria are often isolated in stable state. Whether fungi are also commonly present and associated with clinical and pathological features of disease is uncertain. Objectives To determine the frequency of filamentous fungal culture and sensitisation to Aspergillus fumigatus in COPD and its relationship to clinical outcomes. Methods Subjects with COPD were recruited from a single centre into a 1-year observational study. Assessments of lung function, allergen testing, and sputum analysis for inflammation, bacterial and fungal cultures were undertaken in COPD subjects and in smoking healthy controls. Results Fungi were cultured at baseline in 63/128 subjects of which 47/63 were A fumigatus. A fungus was cultured in 2/11 controls (both were A fumigatus). The total sputum cell count, sputum neutrophil % and inhaled corticosteroid dosage were significantly increased in COPD patients with a positive fungal culture compared to those without a fungal culture (p<0.05), but the within subject repeatability of fungal culture between stable visits was low (K=−0.04). Sensitisation to A fumigatus was present in 13% of COPD subjects and was associated with worse lung function (FEV1 % predicted 39% vs 51%; p=0.01), but not related to fungal culture. Positive fungal cultures were present in 42/110 exacerbations and were not associated with bacterial culture or severity of exacerbation. Conclusions A fumigatus sensitisation is related to poor lung function. Positive fungal culture is a common feature of COPD. The clinical significance of this remains uncertain.