Breathing aspergillus fumigatus unknowingly may lead to allergic bronchopulmonary aspergillosis requiring extra care and immediate aspergillosis treatment.

Aspergillosis

Online Consultation

Ismail Munir

Overview

<p>Aspergillosis is an infection caused by the fungus (mold) Aspergillus fumigatus. It affects the respiratory system<sup><a href="#accordion">[1]</a></sup>. This fungus is present in both indoor and outdoor environments; therefore, most people inhale spores of Aspergillus on a daily basis, yet they do not get infected. However, individuals who have an underlying lung disease or a weakened immune system are more prone to developing an infection by Aspergillus.&nbsp;</p>

<p>The presentation and severity of aspergillosis varies from person to person as some individuals experience a mild form of the disease, while some experience a more serious form of the disease. Some people develop an allergic reaction to Aspergillus, while others develop invasive aspergillosis, which occurs when the mold spreads into the bloodstream and beyond it<sup><a href="#accordion">[2]</a></sup>.</p>

<div>&nbsp;</div>

<p>According to a study, 2.5% of all adults who have asthma also have allergic bronchopulmonary aspergillosis (ABPA). This makes up roughly 4.8 million individuals with aspergillosis worldwide. Moreover, out of these 4.8 million people having ABPA, 400,000 individuals concomitantly have chronic pulmonary aspergillosis (CPA)<sup><a href="#accordion">[3]</a></sup>.</p>

<p>It has been observed that cases of aspergillosis have been reported from all over the world. ABPA affects roughly 1-4 million people, while CPA affects approximately 3 million people; invasive aspergillosis is relatively uncommon<sup><a href="#accordion">[4]</a></sup>.</p>

<p>In Pakistan, rates of CPA are estimated to be 39 per 100,000 people and this high number is attributed to the significant TB burden in the country. Additionally, cases of invasive aspergillosis are estimated to be roughly around 5.9 per 100,000 people<sup><a href="#accordion">[5]</a></sup>.</p>

<div>&nbsp;</div>

<p>There are various types of aspergillosis infection. These include<sup><a href="#accordion">[6]</a></sup>:</p>

<p>&nbsp;</p>

<ul>
	<li>
	<h5><strong>Allergic Bronchopulmonary Aspergillosis (ABPA)</strong></h5>
	</li>
</ul>

<p>ABPA is caused by Aspergillus entering the lung and triggering inflammation and symptoms of allergy, like coughing and wheezing. However, it doesn&#39;t progress to lung infection.</p>

<p>&nbsp;</p>

<ul>
	<li>
	<h5><strong>Allergic Aspergillus Sinusitis</strong></h5>
	</li>
</ul>

<p>This condition occurs when Aspergillus invades the sinuses causing inflammation besides other signs of sinusitis, such as headache, stuffiness, and drainage. This condition also does not cause infection.</p>

<p>&nbsp;</p>

<ul>
	<li>
	<h5><strong>Chronic Pulmonary Aspergillosis</strong></h5>
	</li>
</ul>

<p>As the name suggests, this is a chronic infection of Aspergillus, lasting 3 or more months, affecting the lungs and resulting in cavity formation within the lungs. It also leads to the formation of fungal balls within the lungs, a condition that is known as aspergillomas.&nbsp;</p>

<p>&nbsp;</p>

<ul>
	<li>
	<h5><strong>Cutaneous (Skin) Aspergillosis&nbsp;</strong></h5>
	</li>
</ul>

<p>This type of aspergillosis affects the skin and it occurs when the offending agent Aspergillus makes its way into the body through a break in the skin either due to a burn wound or after surgery. This results in an infection in people with weakened immune systems. Cutaneous aspergillosis can also occur due to invasive aspergillosis where the mold travels from the lungs to the skin through blood, causing cutaneous infection.</p>

<p>&nbsp;</p>

<ul>
	<li>
	<h5><strong>Invasive Aspergillosis&nbsp;</strong></h5>
	</li>
</ul>

<p>This is the most serious form of aspergillosis and it occurs in individuals with weakened immune systems, such as those undergoing stem cell transplant or an organ transplant. This type of aspergillosis affects the lungs most commonly and it spreads to different parts of the body through blood.&nbsp;</p>

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Signs & Symptoms

<p>The presentation of aspergillosis varies with the type of condition that develops.</p>

<p>&nbsp;</p>

<h5><strong>Allergic Bronchopulmonary Aspergillosis (ABPA)&nbsp;</strong></h5>

<p>Individuals with asthma or cystic fibrosis develop an allergic reaction to the mold, Aspergillus. Signs and symptoms of ABPA include<sup><a href="#accordion">[2][4]</a></sup>:</p>

<ul>
	<li>Worsening of asthma</li>
	<li>Coughing up blood or mucus plug</li>
	<li>Fever&nbsp;</li>
	<li>Feeling of poor health (malaise)&nbsp;</li>
</ul>

<p>&nbsp;</p>

<h5><strong>Invasive Aspergillosis&nbsp;</strong></h5>

<p>This is the most severe form of aspergillosis. It occurs when the infection spreads from the lungs. When Aspergillus travels through the blood to different organs of the body such as the heart, brain, kidney, or skin, the condition presents itself with the following signs and symptoms<sup><a href="#accordion">[2][7]</a></sup>:</p>

<ul>
	<li>Fever with chills&nbsp;</li>
	<li>Coughing up of blood (Hemoptysis) or massive bleeding from the lungs&nbsp;</li>
	<li>Chest pain or joint pain&nbsp;</li>
	<li>Kidney or liver failure&nbsp;</li>
	<li>Shortness of breath&nbsp;</li>
	<li>Shock&nbsp;</li>
	<li>Headache or eye symptoms&nbsp;&nbsp;</li>
	<li>Lesions of the skin&nbsp;</li>
</ul>

<p>&nbsp;</p>

<h5><strong>Allergic Aspergillus Sinusitis</strong></h5>

<p>Signs and symptoms of this condition include<sup><a href="#accordion">[1][2]</a></sup>:&nbsp;</p>

<ul>
	<li>Facial pain</li>
	<li>Stuffiness</li>
	<li>Fever</li>
	<li>Decreased ability to smell</li>
	<li>Headaches</li>
</ul>

<p>&nbsp;</p>

<h5><strong>Chronic Pulmonary Aspergillosis&nbsp;</strong></h5>

<p>The clinical presentation of this chronic lung infection includes<sup><a href="#accordion">[1]</a></sup>:</p>

<ul>
	<li>Cough</li>
	<li>Hemoptysis&nbsp;</li>
	<li>Fatigue</li>
	<li>Shortness of breath&nbsp;</li>
	<li>Weight loss&nbsp;</li>
</ul>

<p>&nbsp;</p>

<p>&nbsp;The person should contact their healthcare provider if they notice symptoms of any type of aspergillosis.&nbsp;</p>

<div>&nbsp;</div>

Causes

<p>In the outdoor environment, Aspergillus is found in decaying plant leaves, compost, trees, and grain crops. Healthy individuals rarely develop this infection. Mostly individuals with weakened immune systems, such as diabetic patients, or those infected with HIV, or individuals on immunosuppressive medications, fall prey to this illness since they have fewer white blood cells to fight off the infection.&nbsp;</p>

<p>It can spread from the lung to other parts of the body through invasion of Aspergillus into the bloodstream. Moreover, aspergillosis is not contagious. i.e. it cannot spread from person to person through respiratory droplets or through any other route<sup><a href="#accordion">[2]</a></sup>.</p>

<div>&nbsp;</div>

<p>Individuals who are in the high-risk group of getting aspergillosis should consult with their healthcare provider to get their blood tests done for early detection of invasive aspergillosis since it is a fatal condition<sup><a href="#accordion">[1]</a></sup>.&nbsp;</p>

<p>&nbsp;</p>

Diagnosis

<p>Following tests are done to determine the presence of aspergillosis<sup><a href="#accordion">[8]</a></sup>:&nbsp;</p>

<p>&nbsp;</p>

<ul>
	<li><strong>Imaging Tests:</strong> A chest X-ray or CT scan looks for a fungal mass (also known as aspergilloma) in the lung. Moreover, these tests look for the specific changes in the lungs that are seen with invasive and allergic bronchopulmonary aspergillosis.</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Respiratory Secretion Or Sputum Test:</strong> The healthcare provider collects a sample of the patient&rsquo;s respiratory secretions and sends them to the laboratory to be stained with a dye to check for the presence of filaments of Aspergillus. The sputum sample is also grown in a culture to confirm the presence of the mold.&nbsp;</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Tissue And Blood Tests:</strong> Skin, blood, and sputum are tested for confirming allergic bronchopulmonary aspergillosis. In the skin test, the Aspergillus antigen is inserted and a raised red bump following the introduction of the antigen indicates the presence of allergy to the mold. The blood, on the other hand, is tested for specific antibodies against Aspergillus that confirms the diagnosis of allergic bronchopulmonary aspergillosis.&nbsp;</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Biopsy:</strong> A sample of tissue is collected from the lungs or sinuses and observed under the microscope to make the final diagnosis of invasive aspergillosis.&nbsp;</li>
</ul>

<div>&nbsp;</div>

Treatment

<p>Treatment plans differ based on the types of aspergillosis. It is imperative to seek consultation from a doctor when symptoms develop because treatment is necessary to prevent the condition from progressing<sup><a href="#accordion">[9]</a></sup>.&nbsp;</p>

<p>&nbsp;</p>

<ul>
	<li><strong>Allergic Bronchopulmonary Aspergillosis (ABPA):</strong> Steroid tablets and antifungal tablets are advised for this condition. These medications are to be taken for a few months.&nbsp;</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Chronic Pulmonary Aspergillosis (CPA):</strong> This condition requires long-term treatment with antifungals.</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Aspergilloma:</strong> A fungal ball in the lungs is first treated with antifungals before it is surgically removed.&nbsp;</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Invasive Pulmonary Aspergillosis:</strong> This is a life-threatening condition and antifungal medications are given intravenously to treat it.</li>
</ul>

<div>&nbsp;</div>

<p>Aspergillosis can result in the following complications<sup><a href="#accordion">[2]</a></sup>:</p>

<p>&nbsp;</p>

<ul>
	<li><strong>Bleeding:</strong> Aspergillomas (fungal balls in the lungs) and invasive aspergillosis both have the propensity to cause severe and fatal bleeding within the lungs.&nbsp;</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Systemic Infection:</strong> Invasive aspergillosis is a life-threatening condition since the infection spreads through blood into various organs of the body including the brain, heart, and kidneys.</li>
</ul>

<div>&nbsp;</div>

<p>Aspergillosis depends on the health status of an individual as well as their exposure to molds. The following risk factors increase the likelihood of an individual getting an infection due to Aspergillus<sup><a href="#accordion">[2]</a></sup>:</p>

<p>&nbsp;</p>

<ul>
	<li><strong>Weak Immune System:</strong> Those undergoing bone marrow transplantation, organ transplantation, or cancer chemotherapy are given immunosuppressive medications, which increases the chances of developing invasive aspergillosis. This is because Aspergillus starts to invade the body without facing any hindrance by the immune system of the body that is already in a suppressed state.&nbsp;</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Low White Blood Cells:</strong> Individuals with weak immune systems due to any underlying cause have low levels of white blood cells which means an infection can easily spread throughout the body.&nbsp;</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>An Underlying Lung Condition:</strong> Individuals with existing lung disease, such as cystic fibrosis or asthma, are at an increased risk of developing an allergic response to Aspergillus. Individuals who have had tuberculosis in the past are also at an increased risk of developing aspergillosis. Moreover, individuals who had severe flu or <a href="https://www.merisehat.pk/disease/covid-19" target="_blank">&nbsp;COVID-19</a> infection are also susceptible to getting infected with Aspergillus<sup><a href="#accordion">[9]</a></sup>.&nbsp;</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Lung Cavities:</strong> Individuals who have cavities in their lungs are at an increased risk of developing fungal balls (aspergillomas) within the lungs.&nbsp;</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Long-Term Corticosteroids Therapy</strong>: Prolong use of corticosteroids weaken the immune system and puts the individual at risk of opportunistic infections such as aspergillosis.</li>
</ul>

<div>&nbsp;</div>

<p>It is nearly impossible to avoid Aspergillus mold since it is present in both indoor and outdoor environments, but there are certain steps that can be taken to prevent aspergillosis from developing. The preventive measures are as follows<sup><a href="#accordion">[9]</a></sup>:&nbsp;</p>

<p>&nbsp;</p>

<ul>
	<li>Avoid places where Aspergillus mold is often present such as heaps of compost and pile of dead vegetables and leaves.&nbsp;</li>
	<li>Close the windows to prevent Aspergillus spores from entering especially if there is any construction work happening nearby.&nbsp;</li>
	<li>Wear a face mask for protection in dusty places.</li>
	<li>Install an air purifier at home to cleanse the air of all the dust particles and spores.&nbsp;</li>
	<li>Dry the laundry outside; do not dry it in the bedroom or living area.</li>
</ul>

<div>&nbsp;</div>

<p>The<a href="https://www.merisehat.pk/disease/covid-19" target="_blank"> COVID-19</a> pandemic caused by <a href="https://www.merisehat.pk/disease/severe-acute-respiratory-infection-sari" target="_blank">SARS</a>-CoV-2 resulted in mild to severe respiratory infections. Individuals who were severely infected and admitted to the intensive care unit were at increased risk of acquiring secondary fungal and bacterial infections<sup><a href="#accordion">[10]</a></sup>.&nbsp;</p>

<p>Secondary fungal infections associated with COVID-19 included COVID-19-associated pulmonary aspergillosis (CAPA), invasive candidiasis, and mucormycosis<sup><a href="#accordion">[10]</a></sup>. A study reported that 28.2% of COVID-19 patients were infected with secondary fungal infections during their stay at the hospital. The overall mortality rate was found to be 47.5%<sup><a href="#accordion">[10]</a></sup>. Another study found the mortality associated with CAPA to be 75.2%<sup><a href="#accordion">[10]</a></sup>.&nbsp;</p>

<p>The treatment for CAPA involved Voriconazole, an antifungal, as the first line of treatment and Amphotericin B as the second line of treatment. The duration of antifungal treatment varied from 2-90 days<sup><a href="#accordion">[10]</a></sup>.&nbsp;</p>

<div>&nbsp;</div>

Key Points

<ul>
	<li>Aspergillosis is an illness caused by a variety of fungus (molds) of which Aspergillus fumigatus is the most common.</li>
	<li>The offending agent, Aspergillus, is found both indoors and outdoors.</li>
	<li>Aspergillosis can present in different forms, such as the Allergic Bronchopulmonary Aspergillosis (ABPA), Invasive Aspergillosis, Allergic Bronchopulmonary Sinusitis, Chronic Pulmonary Aspergillosis, and Cutaneous Aspergillosis.&nbsp;</li>
	<li>The signs and symptoms also vary in the different types of aspergillosis.&nbsp;</li>
	<li>The risk factors for aspergillosis include weakened immune state of an individual, low white blood cell count, and an existing underlying lung condition.&nbsp;</li>
	<li>Aspergillosis is diagnosed through imaging studies, such as Chest X-ray and CT scan, sputum, skin, and blood tests.&nbsp;</li>
	<li>Treatment involves the use of antifungals, steroids, and surgery.&nbsp;</li>
</ul>

<div>&nbsp;</div>

[1] Aspergillosis. Centers for Disease Control and Prevention.

[2] Aspergillosis - Symptoms and causes. Mayo Clinic

[3] Aspergillosis statistics. Centers for Disease Control and Prevention.

[4] Aspergillosis - NORD (National Organization for Rare Disorders). NORD (National Organization for Rare Disorders).

[5] Jabeen K, Farooqi J, Mirza S, Denning D, Zafar A. Serious fungal infections in Pakistan. European Journal of Clinical Microbiology &amp; Infectious Diseases. 2017;36(6):949-956. doi:10.1007/s10096-017-2919-6

[6] About aspergillosis. Centers for Disease Control and Prevention.

[7] Aspergillosis: Types, Causes, Symptoms, Treatment & Prevention. Cleveland Clinic.

[8] Aspergillosis - Diagnosis and treatment - Mayo Clinic.

[9] Aspergillosis. NHS.

[10] Sah S, Shariff A, Pathakamuri N et al. Antifungal therapy in the management of fungal secondary infections in COVID-19 patients: A systematic review and meta-analysis. PLoS One. 2022;17(7):e0271795. doi:10.1371/journal.pone.0271795