Epidemiology
- History: ABPA was first described by Hinson in England in 1952 (Thorax, 1952) [MEDLINE]
- Prevalence: ABPA is the most common cause of pulmonary eosinophilia in temperate climates (and probably the most common cause worldwide)
- Age: ABPA is more common in adults than children
- Sex: males are more commonly affected than females in only some reports
- Season: some reports suggest more ABPA episodes in fall and winter (when Aspergillus spore counts are known to be high)
- Intensity of Exposure: in a Chicago study, 80% of exacerbations occurred when mold counts were at their peaks
Diseases Associated with Allergic Bronchopulmonary Aspergillosis
- Asthma (see Asthma, [[Asthma]])
- ABPA Occurs in 1-5% (Some Studies Suggest Up to 28%) of Persistent Asthmatics
- ABPA Occurs in 5-10% of Chronically Steroid-Dependent Asthmatics
- Most Atopic Patients Have a History of Asthma Dating Back to Childhood, But Some Cases Do Not Manifest Asthma Until Years After the Diagnosis of ABPA
- Chronic Granulomatous Disease (see Chronic Granulomatous Disease, [[Chronic Granulomatous Disease]])
- Epidemiology: ABPA rarely occurs in patients with CGD
- Cystic Fibrosis (CF) (see Cystic Fibrosis, [[Cystic Fibrosis]])
- ABPA Occurs in 2-9% of Cystic Fibrosis Patients
- Hyper IgE-Recurrent Infection Syndrome (Job’s Syndrome, Buckley-Job Syndrome) (see Hyper IgE-Recurrent Infection Syndrome, [[Hyper IgE-Recurrent Infection Syndrome]])
- Epidemiology: ABPA rarely occurs in these patients
- Lung Transplant (see Lung Transplant, [[Lung Transplant]])
- Epidemiology: ABPA rarely occurs in lung transplant patients
Microbiology
Organisms Associated with Allergic Bronchopulmonary Mycosis (Crit Rev Microbiol, 2014) [MEDLINE]
- Aspergillus Fumigatus (see Aspergillus, [[Aspergillus]]): most common etiology
- Other Aspergillus Species (see Aspergillus, [[Aspergillus]])
- Aspergillus Niger
- Aspergillus Oryzae: associated with exposure in a soy sauce factory
- Aspergillus Ochraceus
- Other Aspergillus Species (see Aspergillus, [[Aspergillus]])
- Candida Albicans (see Candida, [[Candida]])
- Epidemiology: second most common etiologic organism (accounts for 60% of non-Aspergillus cases)
- Bipolaris: accounts for 13% of of non-Aspergillus cases
- Schizophyllum Commune: accounts for 11% of non-Aspergillus cases
- Curvularia: accounts for 8% of non-Aspergillus cases
- Scedosporium (Pseudallescheria Boydii) (see Scedosporiosis, [[Scedosporiosis]]): accounts for 3% of non-Aspergillus cases
- Alternaria Alternata: rare non-Aspergillus etiology
- Candida Glabrata: rare non-Aspergillus etiology
- Cladosporium Cladosporioides: rare non-Aspergillus etiology
- Fusarium Vasinfectum: rare non-Aspergillus etiology
- Helminthosporium: rare non-Aspergillus etiology
- Penicillium Species: rare non-Aspergillus etiology
- Rhizopus Oryzae: rare non-Aspergillus etiology
- Saccharomyces Cerevisiae: rare non-Aspergillus etiology
- Stemphylium Languinosum: rare non-Aspergillus etiology
- Trichosporon Beigelii: rare non-Aspergillus etiology
Physiology
Pathogenesis is Unclear
- Exposure of Atopic Patients to Fungal Spores Results in IgE and IgG Responses
- In Contrast, Healthy Patients are Able to Effectively Eliminate Fungal Spores from the Airways
- T-Cells Play an Important Role
Pathologic Findings
- Bronchocentric Granulomatosis
- Eosinophilic Pneumonia: although this may occasionally be found, this is not a major feature of ABPA
- Histologic Features of Asthma
- Mucoid Impaction of Bronchi
- Presence of Septated Hyphae with Acute Dichotomous Branching in the Mucous-Filled Bronchial Lumen
- Absence of Fungal Invasion of the Mucosal Wall
Diagnosis
Complete Blood Count (CBC) (see Complete Blood Count, [[Complete Blood Count]])
- Peripheral Eosinophilia (see Peripheral Eosinophilia, [[Peripheral Eosinophilia]])
- Elevated: >500/mm3 (Often >1000/mm3)
- Peripheral Eosinophilia May Decrease Following Glucocorticoid Administration
- Peripheral Eosinophilia >2000/mm3: should raise the consideration of other diagnoses, such as Churg-Strauss syndrome and hypereosinophilic syndromes
Aspergillus Skin Testing
- Positive
- Positive Immediate Skin Test Reactivity to Aspergillus Fumigatus is Present in 20-30% of All Asthmatics (Chest, 2000) [MEDLINE]: this subset of asthmatics has been termed “Severe Asthma with Fungal Sensitization” (SAFS) (see Asthma, [[Asthma]])
- These Asthmatics May Respond to Itraconazole Therapy (FAST Trial) (Am J Respir Crit Care Med, 2009) [MEDLINE]
- Positive Immediate Skin Test Reactivity to Aspergillus Fumigatus is Present in 20-30% of All Asthmatics (Chest, 2000) [MEDLINE]: this subset of asthmatics has been termed “Severe Asthma with Fungal Sensitization” (SAFS) (see Asthma, [[Asthma]])
Serum Immunoglobulin E (IgE) (see Serum Immunoglobulin E, [[Serum Immunoglobulin E]])
- Elevated: >1000 IU/mL (International Society for Human and Animal Mycology, ISHAM) (Clin Exp Allergy, 2013) [MEDLINE]
- Generally Higher in ABPA than in Asthma
- May Be as High as 25k IU/mL
- Serum IgE May Decrease (But Does Not Usually Normalize) Following Glucocorticoid Administration
- Recommendations (Infectious Diseases Society of America 2016 Aspergillosis Diagnosis and Treatment Guidelines) (Clin Infect Dis, 2016) [MEDLINE]
- Total Serum IgE and Aspergillus-Specific IgE are Recommended for Diagnosis and Screening (Strong Recommendation, High-Quality Evidence)
Aspergillus-Specific Immunoglobulin E (IgE)
- Elevated: >0.35 kU/L (International Society for Human and Animal Mycology, ISHAM) (Clin Exp Allergy, 2013) [MEDLINE]
- Recommendations (Infectious Diseases Society of America 2016 Aspergillosis Diagnosis and Treatment Guidelines) (Clin Infect Dis, 2016) [MEDLINE]
- Total Serum IgE and Aspergillus-Specific IgE are Recommended for Diagnosis and Screening (Strong Recommendation, High-Quality Evidence)
Serum Immunoglobulin G (IgG) (see Serum Immunoglobulin G, [[Serum Immunoglobulin G]])
- Elevated: non-specific
Aspergillus Serum Precipitins
- Precipitating Aspergillus Antibodies: useful diagnostically, but not useful for follow-up or monitoring
- Newer Assays Can Detect Specific IgG Antibodies Against Aspergillus Antigens
Pulmonary Function Tests (PFT’s) (see Pulmonary Function Tests, [[Pulmonary Function Tests]])
- Obstruction
- Gas Trapping: increased RV/TLC ratio
- Positive Bronchodilator Response: present in <50% of cases
Bronchoscopy (see Bronchoscopy, [[Bronchoscopy]])
- May Be Necessary in Some Cases for Diagnostic Purposes or to Clear Mucous Plugging of Airways
Sputum Culture (see Sputum Culture, [[Sputum Culture]])
- Gross Findings
- Bronchial Casts
- Pellets
- Plugs
- Thick Lumps
- Microscopic Features
- Charcot-Leyden Crystals
- Curschmann’s Spirals
- Eosinophils
- Microbiologic Features
- Aspergillus Can Be Grown from Sputum of Approximately 66% of ABPA Patients: although hyphae may not be seen by microscopy
Chest X-Ray (CXR) (see see Chest X-Ray, [[Chest X-Ray]])
- Indications
- May Be Used as Initial Radiologic Evaluation: however, CXR is not sensitive enough to detect the presence or extent of bronchiectasis in ABPA
- CXR is Normal in 50% of ABPA Cases (World J Radiol, 2012) [MEDLINE]
- May Be Used as Initial Radiologic Evaluation: however, CXR is not sensitive enough to detect the presence or extent of bronchiectasis in ABPA
- Findings
- Atelectasis (see Atelectasis, [[Atelectasis]]): due to mucoid impaction
- Consolidation
- Fleeting Pulmonary Opacities: usually involving the upper lobes preferentially
- Findings Suggestive of Bronchiectasis
- Gloved Finger Shadows (Branched Tubular Densities 2-3 cm Long and 5-8 mm Wide That Extend From the Hilum): due to intrabronchial exudates with bronchial wall thickening
- Parallel Lines: due to ectatic bronchi
- Peri-Hilar Opacities (Mimicking Hilar Lymphadenopathy): due to mucous plugging
- Ring Shadows: due to bronchial wall thickening or saccular bronchiectasis
- Toothpaste Shadows: due to mucoid impaction 2nd-4th order bronchi
- Tram Track Opacities: due to thickened walls of non-dilated bronchi
High-Resolution Chest CT (HRCT) (see High-Resolution Chest Computed Tomography, [[High-Resolution Chest Computed Tomography]])
- Indications
- HRCT is the Imaging Procedure of Choice to Diagnose Bronchiectasis in ABPA
- Sensitivity for Bronchiectasis: 96-98%
- Specificity for Bronchiectasis: 93-98%
- HRCT is the Imaging Procedure of Choice to Diagnose Bronchiectasis in ABPA
- Findings
- Normal: 37% of cases had normal HRCT in recent studies (Current Probl Diagn Radiol, 2016) [MEDLINE]
- Atelectasis (see Atelectasis, [[Atelectasis]])
- Bronchiectasis (see Bronchiectasis, [[Bronchiectasis]]): common
- Central Bronchiectasis with Bronchial Wall Thickening is Classically Present with Upper Lobe Predominance: however, peripheral bronchiectasis may also be seen
- Consolidation: may be seen in some cases
- However, HRCT Studies Suggest that Most Consolidations Identified on CXR are Actually Mucous-Filled Bronchi (Current Probl Diagn Radiol, 2016) [MEDLINE]
- Ground-Glass Infiltrates: may be seen in some cases
- Mosaic Perfusion/Air Trapping: may be seen in some cases
- Mucoid Impaction (see Mucoid Impaction, [[Mucoid Impaction]]): common
- Mucoid Impaction May Be Hypodense or Hyperdense (Denser Than Paraspinal Skeletal Muscle)
- Hyperdense Mucoid Impaction Occurs in 18-28% of Cases
- When Present, the Hyperdensity Has Been Attributed to the Presence of Calcium Salts, Metals, or Desiccated Mucous
- High Attenuation Mucoid Impaction on HRCT (>100 Hounsfield Units) was Correlated with Significantly Higher Values of Serum IgE, Specific IgE, and Number of Bronchial Segments Affected (Current Probl Diagn Radiol, 2016) [MEDLINE]
- Mucoid Impaction May Be Hypodense or Hyperdense (Denser Than Paraspinal Skeletal Muscle)
- Tree-in-Bud Opacities (see Tree-in-Bud Sign, [[Tree-in-Bud Sign]]): may be seen
Bronchogram
- No Longer Performed: due to invasive nature and risk of adverse effects
Clinical Diagnostic Criteria for Allergic Bronchopulmonary Aspergillosis (ABPA) (International Society for Human and Animal Mycology, ISHAM) (Clin Exp Allergy, 2013) [MEDLINE]
Predisposing Criteria (One Must Be Present)
- Asthma (see Asthma, [[Asthma]])
- Cystic Fibrosis (CF) (see Cystic Fibrosis, [[Cystic Fibrosis]])
Obligatory Criteria (Both Must Be Present)
- Positive Aspergillus Skin Test or Detectable Aspergillus Fumigatus-Specific IgE
- Aspergillus Skin Prick Test: >3mm wheel 10 min after skin prick (usually with negative reaction to other allergens)
- Aspergillus Intradermal Skin Test
- ISHAM Definition of Elevation of Aspergillus Fumigatus-Specific IgE: >0.35 kU/L
- Elevated Serum IgE
- ISHAM Definition of Elevation of Serum IgE: >1000 IU/mL
- May Be <1000 IU/mL, if Patient Meets All Other Criteria
- ISHAM Definition of Elevation of Serum IgE: >1000 IU/mL
Other Criteria (At Least Two Must Be Present)
- Precipitating Serum Antibodies to Aspergillus Fumigatus or Elevated Serum Aspergillus IgG by Immunoassay
- Radiographic Pulmonary Opacities Consistent with the Diagnosis of ABPA
- Peripheral Eosinophilia (Eosinophil Count >500 cells/μL) in Corticosteroid-Naive Patient: may be historical
Clinical Diagnosis in Patients with Cystic Fibrosis (CF) (see Cystic Fibrosis, [[Cystic Fibrosis]]) (Cystic Fibrosis Foundation Consensus Conference Guidelines) (Clin Infect Dis, 2003) [MEDLINE]
- Maintain High Clinical Suspicion for ABPA in CF Patients >6 y/o: especially in those with clinical deterioration
- Measure Total Serum IgE Annually
- *If Serum IgE 200-500 IU/mL, Repeat the Measurement if Clinical Suspicion is High and Consider Other Evaluation (Chest X-Ray, Aspergillus Precipitins, Aspergillus Fumigatus-Specific IgE, Aspergillus Skin Test, etc)
- If Serum IgE >500 IU/mL, Evaluate with Aspergillus Fumigatus-Specific IgE and Aspergillus Skin Test
Clinical Manifestations
General Comments
- ABPA May Be Asymptomatic in Some Cases
Otolaryngologic Manifestations
Allergic Fungal Rhinosinusitis (see Chronic Rhinosinusitis, [[Chronic Rhinosinusitis]])
- Epidemiology: allergic fungal rhinosinusitis may occur coexistent with ABPA in small percentage of cases
- Clinical: allergic fungal rhinosinusitis is a distinct type of chronic rhinosinusitis
Pulmonary Manifestations
Asthma-Like Presentation with Recurrent Exacerbation (see Asthma, [[Asthma]])
- Epidemiology: characteristic clinical presentation
- Clinical: typically with recurrent exacerbation
- Bronchospasm/Wheezing (see Obstructive Lung Disease, [[Obstructive Lung Disease]]): variably present
- Chest Pain (see Chest Pain, [[Chest Pain]])
- Cough (see Cough, [[Cough]])
- Expectoration of Bronchial Casts: occurs in 66% of cases
- Mucopurulent/Bloody Sputum: occurs in some cases
- Dyspnea (see Dyspnea, [[Dyspnea]])
Atelectasis (see Atelectasis, [[Atelectasis]])
- Epidemiology: may occur in some cases
- Clinical
- Right Middle Lobe Syndrome
Pneumonia-Like Presentation (see Pneumonia, [[Pneumonia]])
- Epidemiology: may occur in some cases
- Clinical
- Chest Pain (see Chest Pain, [[Chest Pain]])
- Cough (see Cough, [[Cough]])
- Expectoration of Bronchial Casts: occurs in 66% of cases
- Mucopurulent/Bloody Sputum (see Hemoptysis, [[Hemoptysis]]): occurs in some cases
- Dyspnea (see Dyspnea, [[Dyspnea]])
Lung Nodule/Mass (see Lung Nodule or Mass, [[Lung Nodule or Mass]])
- Epidemiology: may occur in some cases
- Physiology
- Mucoid Impaction (see Mucoid Impaction, [[Mucoid Impaction]])
Pulmonary Fibrosis
- Epidemiology: may occur in advanced cases
- Physiology: recurrent inflammation
Other Manifestations
- Fever (see Fever, [[Fever]])
- Epidemiology: occurs in 10% of cases
- Malaise
- Night Sweats
Complications
- Aspergilloma (see Aspergillus, [[Aspergillus]])
- Epidemiology
- Rare Complication of ABPA (Ann Allergy Asthma Immunol, 2006) [MEDLINE]
- Epidemiology
- Chronic Pulmonary Aspergillosis (see Aspergillus, [[Aspergillus]])
- Epidemiology
- Rare Complication of ABPA (Respir Med, 2015) [MEDLINE]
- Epidemiology
- Invasive Pulmonary Aspergillosis (see Aspergillus, [[Aspergillus]])
- Epidemiology
- Rare Complication of ABPA (Mycopathologia, 2015) [MEDLINE]
- May Occur During Itraconazole Therapy: may be due to immunosuppressive effects of corticosteroids
- Epidemiology
Treatment
Acute Allergic Bronchopulmonary Aspergillosis (ABPA)
Systemic Corticosteroids and Azole Antifungals
- Indications
- Acute ABPA with Radiographic Opacities (Usually Upper/Middle Lobes and Serum IgE >1000 IU/mL
- Administration
- Prednisone (see Prednisone, [[Prednisone]]): 0.5 mg/kg qday x 14 days (although some patients require a higher prednisone dose of 40-60 mg/day for acute asthma exacerbation)
- Subsequently, Change to Every Other Day Prednisone Dosing
- Subsequently, Taper Prednisone Off at 3 mo
- Itraconazole (Sporanox) (see Itraconazole, [[Itraconazole]]): 200 mg TID x 3 days, then 200 mg BID x 16 wks
- Rationale for Antifungal Component of Therapy: to decrease the corticosteroid dose
- Alternative: Voriconazole (Vfend) (see Voriconazole, [[Voriconazole]]): 400 mg PO BID x 2 doses, then 200 mg PO BID x 16 wks
- Voriconazole is Better Absorbed and Has Better Gastrointestinal Tolerance Than Itraconazole
- Prednisone (see Prednisone, [[Prednisone]]): 0.5 mg/kg qday x 14 days (although some patients require a higher prednisone dose of 40-60 mg/day for acute asthma exacerbation)
- Monitoring
- Serum IgE (Measured Every 1-2 mo): serum IgE generally decreases by 25% after 1 month of treatment and by 60% after 2 months of treatment (Ann Thorac Med, 2014)[MEDLINE]
- Decrease of 35% is Considered a Good Therapeutic Response: this merits tapering of prednisone
- Note: Aspergillus-specific IgE is not considered useful for monitoring
- Serum IgE (Measured Every 1-2 mo): serum IgE generally decreases by 25% after 1 month of treatment and by 60% after 2 months of treatment (Ann Thorac Med, 2014)[MEDLINE]
- Clinical Efficacy
- Corticosteroid Use is Based Largely on Case Series, as No Clinical Trials Have Been Performed (Arch Intern Med, 1986) [MEDLINE] and (Chest, 2006) [MEDLINE
- Trial of Itraconazole in Corticosteroid-Dependent ABPA (NEJM, 2000) [MEDLINE]
- Itraconazole (x 16 wks) Increased Clinical Response Over Corticosteroids Alone
- Trial of Itraconazole in Stable ABPA (J Allergy Clin Immunol, 2003) [MEDLINE]
- Itraconazole (x 16 wks) Decreased Corticosteroid-Requiring Exacerbations in ABPA
- Recommendations (Infectious Diseases Society of America 2016 Aspergillosis Diagnosis and Treatment Guidelines) (Clin Infect Dis, 2016) [MEDLINE]
- ABPA with Bronchiectasis and/or Mucoid Impaction Should Be Treated with Corticosteroids and Itraconazole (with Therapeutic Drug Monitoring) (Weak Recommendation; Low-Quality Evidence)
Acute Allergic Bronchopulmonary Aspergillosis (ABPA) in Remission
- Definition of Remission: normal-mildly increased serum IgE and absence of radiographic findings in a patient who has been off corticosteroids for >6 mo
- Inhaled Corticosteroids (see Corticosteroids, [[Corticosteroids]]): used to maintain asthma control
- Monitoring
- Pulmonary Function Tests (PFT’s) (Annually or In Response to Symptoms) (see Pulmonary Function Tests, [[Pulmonary Function Tests]])
- Serum IgE (Measured Every 3-6 mo): increase in serum IgE may precede or accompany radiographic changes or peripheral eosinophilia
Acute Allergic Bronchopulmonary Aspergillosis (ABPA) Exacerbation
- Exacerbations May Be Frequent
- Exacerbations May Be Asymptomatic, Being Detected Only by Serum IgE and Radiographic Changes
- Corticosteroids in Doses Adequate to Maintain Control of Asthma May Be Inadequate to Prevent Exacerbations of ABPA: for this reason serum IgE monitoring is useful
- Agents
- Omalizumab (Xolair) (see Omalizumab, [[Omalizumab]])
- Clinical Efficacy
- Trial of Omalizumab in ABPA with Poorly-Controlled Asthma (J Allergy Clin Immunol Pract, 2015) [MEDLINE]
- Omalizumab Can Be Used to Treat ABPA, Despite High Serum IgE
- Trial of Omalizumab in ABPA with Poorly-Controlled Asthma (J Allergy Clin Immunol Pract, 2015) [MEDLINE]
Other Interventions
- Avoidance of Aspergillus Exposure: while avoidance of exposure seems logical, its impact is not clear
- Allergen Immunotherapy (see Allergen Immunotherapy, [[Allergen Immunotherapy]]): unclear role
- Bronchoscopy (see Bronchoscopy, [[Bronchoscopy]]): may be required in some cases to clear mucous plugs
- Inhaled Corticosteroids (see Corticosteroids, [[Corticosteroids]])
- Inhaled Corticosteroids are Not Believed to Have No Role in the Management of Serologically-Diagnosed ABPA, But May Be Useful as an Adjunct to Treat Asthmatic Symptoms (Intern MED, 2011) [MEDLINE]
- Nebulized Amphotericin B (see Amphotericin, [[Amphotericin]]): has been reported to be efficacious in childhood cases with associated cystic fibrosis
Treatment of Acute Allergic Bronchopulmonary Aspergillosis (ABPA) in Patients with Cystic Fibrosis (CF) (see Cystic Fibrosis, [[Cystic Fibrosis]])
- General Approach: treat as per standard therapy above
- Clinical Efficacy
- Trial of Itraconazole in ABPA Associated with CF (Chest, 1999) [MEDLINE]
- Recommendations (Infectious Diseases Society of America 2016 Aspergillosis Diagnosis and Treatment Guidelines) (Clin Infect Dis, 2016) [MEDLINE]
- In Patients with CF with Frequent Exacerbations and/or Decreasing FEV1, Itraconazole is Suggested (with Therapeutic Drug Monitoring) to Minimize Corticosteroid Use (Weak Recommendation; Low-Quality Evidence): if therapeutic levels of itraconazole cannot be achieved, other azole antifungals should be considered
Prognosis
- Prognosis of Serologic ABPA with Normal HRCT (Respir Med, 2012) [MEDLINE]: mean follow-up duration was 43.7 +/- 10.1 mo
- No Patients Developed Central Bronchiectasis
References
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- Allergic bronchopulmonary aspergillosis. Natural history and classification of early disease by serologic and roentgenographic studies. Arch Intern Med. 1986;146(5):916 [MEDLINE]
- Allergic bronchopulmonary aspergillosis in cystic fibrosis: role of atopy and response to itraconazole. Chest. 1999;115(2):364 [MEDLINE]
- Allergic bronchopulmonary aspergillosis in the asthma clinic. A prospective evaluation of CT in the diagnostic algorithm. Chest. 2000;118(1):66 [MEDLINE]
- A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis. N Engl J Med. 2000;342(11):756 [MEDLINE]
- Diagnosis and treatment of allergic bronchopulmonary aspergillosis. Mayo Clin Proc. 2001;76(9):930 [MEDLINE]
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- Allergic bronchopulmonary aspergillosis: lessons from 126 patients attending a chest clinic in north India. Chest. 2006 Aug;130(2):442-8 [MEDLINE]
- Allergic bronchopulmonary aspergillosis in cystic fibrosis–state of the art: Cystic Fibrosis Foundation Consensus Conference. Clin Infect Dis. 2003;37 Suppl 3:S225 [MEDLINE]
- Contemporaneous occurrence of allergic bronchopulmonary aspergillosis, allergic Aspergillus sinusitis, and aspergilloma. Ann Allergy Asthma Immunol. 2006 Jun;96(6):874-8 [MEDLINE]
- Allergic bronchopulmonary aspergillosis. Chest. 2009;135(3):805 [MEDLINE]
- Randomized controlled trial of oral antifungal treatment for severe asthma with fungal sensitization: The Fungal Asthma Sensitization Trial (FAST) study. Am J Respir Crit Care Med. 2009;179(1):11 [MEDLINE]
- Role of inhaled corticosteroids in the management of serological allergic bronchopulmonary aspergillosis (ABPA). Intern Med. 2011;50(8):855-60. Epub 2011 Apr 15 [MEDLINE]
- Chest radiographic and computed tomographic manifestations in allergic bronchopulmonary aspergillosis. World J Radiol. 2012 Apr 28;4(4):141-50. doi: 10.4329/wjr.v4.i4.141 [MEDLINE]
- Serologic allergic bronchopulmonary aspergillosis (ABPA-S): long-term outcomes. Respir Med. 2012 Jul;106(7):942-7. Epub 2012 Mar 23 [MEDLINE]
- Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria. Clin Exp Allergy. 2013;43(8):850 [MEDLINE]
- Allergic bronchopulmonary mycosis due to fungi other than Aspergillus: a global overview. Crit Rev Microbiol. 2014 Feb;40(1):30-48. Epub 2013 Feb 5 [MEDLINE]
- Allergic bronchopulmonary aspergillosis: A clinical review of 24 patients: Are we right in frequent serologic monitoring? Ann Thorac Med. 2014 Oct;9(4):216-20 [MEDLINE]
- Acute Invasive Pulmonary Aspergillosis Complicating Allergic Bronchopulmonary Aspergillosis: Case Report and Systematic Review. Mycopathologia. 2015;180(3-4):209 [MEDLINE]
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- Clinical efficacy and immunologic effects of omalizumab in allergic bronchopulmonary aspergillosis. J Allergy Clin Immunol Pract. 2015 Mar;3(2):192-9. Epub 2015 Jan 29 [MEDLINE]
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