Clinical Characteristics Of 47 Patients With Allergic Bronchopulmonary Aspergillosis Diagnosed For The First Time

BackgroundABPA is an allergic lung disease caused by the sensitization to aspergillus that is colonized at the respiratory tract.Aspergillus fumigatus is the most common allergen.With the development of serological and imaging diagnostic methods in recent years,more and more studies have shown that ABPA is not a rare disease,and it is easy to be missed or misdiagnosed because of the various predisposing factors and clinical manifestations and atypical imaging manifestations.At the same time,most of the existing diagnostic criteria regard asthma history as the main or necessary diagnostic conditions.However,it is found that there are not a few patients of ABPA without asthma history in clinical practice,who are more likely to be missed diagnosis and misdiagnosis.Diagnosis and treatment early could avoid the progression to irreversible and fatal injury stages,such as bronchiectasis,pulmonary fibrosis and chronic aspergillosis.But currently the understanding of ABPA,especially the early clinical characteristics of the disease is not sufficient.ObjectiveIn order to improve clinicians’understanding of ABPA and the ability of diagnosis and treatment,we analyse and summarize patients’clinical data of ABPA diagnosed for the first time comprehensively.It may help to diagnose the disease early and to treat it aggressively so as to to prevent irreversible lung injury.Meanwhile we analyze the correlation immunologic indicators,imaging classification and the severity of bronchiectasis in the acute phase and explore the significance of clinical indicators,which may provide the basis for disease assessment,diagnostic and therapeutic program formulation.MethodsThis is a retrospective study.We retrieved discharging cases diagnosed as"allergic bronchopulmonary aspergillosis"with the ICD-10（B44.101+J99.8）from January 1,2013 to December 31,2019 in the First Affiliated Hospital of Guangzhou Medical University.Each case’s history and clinical data in detail were reviewed.The diagnostic criteria of ABPA refered to the Chinese Expert Consensus on Diagnosis and Treatment of ABPA in 2017.Patients were excluded if they met any of the following criteria:（a）have been diagnosed and treated normatively in the external hospital;（b）intake of systemic corticosteroids for a total of more than 3 weeks within the last six month;（c）have other diseases including autoimmune diseases or systemic diseases,parasitic infections and tumors,lung infections with bacteria or special pathogens.According to this criteria,the clinical data of ABPA patients diagnosed for the first time were collected.The clinical features,imaging findings,biomarkers were analyzed.The correlation of serological indicators of different clinical subtypes and the severity of bronchiectasis was also explored.ResultsWe reviewed 109 cases of"allergic bronchopulmonary aspergillosis"in the discharging diagnosis,of which 73 cases met the diagnostic criteria agreed by the Chinese Expert Consensus on Diagnosis and Treatment of ABPA in 2017.After excluding confounding factors from baseline biomarkers and imaging findings,this study included47 ABPA patients diagnosed for the first time.Among them,24 cases were misdiagnosed as pulmonary tuberculosis in 7 cases,lung tumor in 2 cases,bacterial pneumonia in 10cases,fungal infection in 2 cases,eosinophil pneumonia in 3 cases.For basic diseases,there were 30 cases with asthma and 17 cases without asthma,10 of whom with bronchiectasis,3 with chronic obstructive pulmonary disease,2 with airway stenosis after pulmonary tuberculosis,2 with unknown basic disease because of the short course of disease.Of the 47 patients,24 cases were male（51.06%）and 23 cases were female（48.94%）with an average age of（46±16）years and an average BMI index of（21.71±3.29）（kg/m²）.The main clinical symptoms were cough（47（100%））,expectoration in（45（95.74%））,wheezing（28（59.57%））,shortness of breath（18（38.30%））,hemoptysis（15（31.91%））,chest tightness（10（21.28%））,chest pain（8（17.02%））,cough brown sputum and feve（3（6.5%））.The main features of HRCT were pleomorphic lung infiltration shadow distributing around the dilated trachea,central bronchiectasis and mucus impaction.The imaging performances of HRCT included fragmental infiltrates（33（70.12%））,mucus plug（28（59.57%））,central bronchiectasis（26（55.32%））,airway thickening（24（51.06%））,mediastinal and/or hilar lymphadenopathy（20（42.55%））,tree-in-bud pulmonary and pleural thickening（9（19.15%））,consolidation（6（12.77%））and so on.Laboratory examination results:all immunological indexes of 47 patients had elevated,and the median of peripheral blood eosinophils,blood eosinophil ratio,serum total IgE and aspergillus specific IgE were 660 cells/u L,9.0%,1775k U/L and5.27k UA/L respectively.While the FEV₁%pred averaged（59.87±25.00）%in 37 patients and（60.08±21.11）%in FEV₁/FVC.The median value of carcinoembryonic antigen in36 patients was 4.73（2.42-8.77）ng/ml,and there was a weak positive correlation between serum CEA level and specific IgE against aspergillus level before treatment（R=0.378,p=0.023）.The level of CEA was statistically different between groups with or without mucoid impaction on HRCT,p values was 0.0068.After treatment,the CEA level of 7 patients were significantly decreased,even decreased to normal.There were 17 cases（36.17%）of serologic ABPA（ABPA-S）and 30 cases（63.83%）of ABPA with bronchiectasis（ABPA-B）according to the presentation of HRCT.The proportion of mucus plugs in ABPA-B group was significantly higher than that in ABPA-S group（80.0%vs 23.5%,p<0.001）.Absolute eosinophil count and Total IgE levels were higher than normal in both groups,but there was no significant difference between the types of ABPA.In contrast,the level of A.fumigatus-specific IgE in ABPA-B group was significantly higher than in ABPA-S group（11.19 vs 1.22 KUA/L,p=0.001）.And there was a good positive correlation between A.fumigatus-specific IgE levels and the degree of bronchiectasis（Reiff score,No.of bronchial segments and lobes affected）,with the correlation coefficients 0.484,0.486 and 0.513（all p≤0.001）respectively.Conclusion1.ABPA is more common in patients with chronic inflammatory airway disease and it alerts us to patients of ABPA without the history of asthma.2.Patients of ABPA have atypical clinical and imaging features.They were characterized by chronic cough,expectoration and wheezing.The main features of imaging were pleomorphic lung infiltration shadow distributing around the dilated trachea,central bronchiectasis and mucus impaction.3.Those who have mucoid impaction on HRCT,their serum CEA can be elevated in the acute phase and be reduced to normal after treatment.4.Compared with ABPA-S group,ABPA-B group was more prone to mucus plug.5.A.fumigatus-specific IgE level is significantly higher in ABPA-B group than in ABPA-S group.And there is a good positive correlation between A.fumigatus-specific IgE and the severity of bronchiectasis（Reiff score,No.of bronchial segments and lobes affected）,which indicates that the higher s IgE,the more severe the bronchiectasis and helps to assess the severity of disease and reduce unnecessary repeated CT checks.