Complications
One of the criteria for diagnosis of allergic bronchopulmonary aspergillosis (ABPA) with central bronchiectasis. Because ABPA is usually diagnosed at stage 4 or 5, bronchiectasis is noted in these stages in all cases. Usually described as central bronchiectasis with bilateral dilation of central or upper lobe bronchi.
Thought to develop as a consequence of the intense inflammatory reaction in the bronchi to Aspergillus fumigatus. This leads to airway damage and remodelling.
If ABPA is suspected in a patient with asthma who is also skin-prick test-positive to A fumigatus, perform high-resolution computed tomography scan of the chest to differentiate ABPA from severe asthma. Prompt evaluation and treatment of ABPA can prevent progression to bronchiectasis.
Because bronchiectasis is irreversible, management is supportive, with sputum clearance techniques for mucus hypersecretion, antimicrobial therapy for infectious bronchitis, and bronchodilators and pulmonary rehabilitation for airflow obstruction.
Fibrosis is a feature of stage 5 disease (the second most common stage at which allergic bronchopulmonary aspergillosis is diagnosed). The inflammatory response in the bronchi that leads to bronchiectasis may progress to fibrosis, due to persistent inability to clear mucus containing A fumigatus fungal elements. This promotes further accumulation of inflammatory cells, which destroy the lung parenchyma by their toxic exoproducts.[77][72]
Includes metabolic abnormalities such as diabetes, osteopenia, and hyperlipidaemia. Immune suppression, cataracts, and growth retardation, especially in patients with cystic fibrosis, can also be seen. These adverse effects have prompted the alternative approach of adding an antifungal agent as a corticosteroid-sparing agent.
If long-term corticosteroid use is anticipated, suggested baseline measurements include: body weight, height and blood pressure; bone mineral density; and basic laboratory tests such as full blood count, blood glucose values, and lipid profile.[78]
Adrenal suppression has been reported following use of systemic corticosteroids and azole antifungals; both agents can cause adrenal suppression in their own right.[51]
While all azole antifungals can decrease the hepatic clearance of corticosteroids resulting in increased corticosteroid plasma concentrations, a case report of voriconazole toxicity following cessation of corticosteroid treatment in a patient with allergic bronchopulmonary aspergillosis suggests that corticosteroids can also induce metabolism of voriconazole. Therefore, close monitoring is recommended when both agents are used concurrently.[52]
Hepatic toxicity has also been reported with some antifungals.[79]
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