ABPA or APC?

Question

Dear expert team,

I am 22 years old and have CF. For some time now, my IgE has repeatedly been elevated (above 500). A RAST sensitivity class 3 to aspergillus is given; the sputum showed candida above all. The remaining values do not point to ABPA.

Does this suggest ABPA? Or could it be ACP? I got significantly better (esp. the sputum amount) during treatment with Sempera®/itraconazole, except for my blood sugar (I have CF-related diabetes), which is pretty out of control. This is due to the itraconazole, isn’t it? Would a cortisone therapy make sense then? Are there any alternatives?

Kind regards.

Answer

Hello,

ABPA (allergic bronchopulmonary aspergillosis) is a disease caused by a defense reaction of the body against allergens of the mould fungus aspergillus fumigatus that involves the lungs. You are asking whether you might have ABPA, which therapy options there are, and whether there are any alternatives to systemic cortisone therapy.

The information you provide does not allow for ABPA to be ruled out, but it is not at all clear enough to confirm an ABPA diagnosis (let alone over the internet), nor does it allow for a distinction from allergic pulmonary candidiasis (which is what you mean by the abbreviation APC, I assume?). I can, however, try to assist you by giving you hints that could help facilitate a conversation with your CF doctor to clarify the diagnosis.

To find out whether you have ABPA, the following main aspects should be considered:

What are your current troubles (noticeable dyspnea)?
Do you have a temporary decrease in FEV1 not related to an infection?
Have you had an increase in IgE (here the progress is very important; usually values above 1000 suggest ABPA)?
What about the specific IgE (continuous RAST tests)?
What is the result of the specific IgG?
Is aspergillus (candida) detectable in the sputum? (You are saying that aspergillus was not found but candida was; however, evidence of the fungi in the sputum is no proof of the disease.)
Are there any new and recent radiological changes (a CT of the thorax can be very helpful here)?

Only a synopsis of all results can lead to a diagnosis. If the ABPA diagnosis is made, and after weighing the therapy effects and side effects, a systemic cortisone (systemic) and itraconazole (Sempera®) therapy should be started and carried out for the time necessary. Here, your diabetes should be kept in mind. At this point, there is no real alternative to a cortisone therapy for ABPA. However, it is always necessary to check carefully whether a systemic cortisone therapy is really necessary.

For patients prone to recurrent ABPA, a decision about long-term itraconazole therapy has to be made.

Also, it should be checked whether the patient lives in a virtually mould-free environment.

Please talk to your CF doctor about all of these aspects. I am confident that you will then get adequate therapy.

Kind regards
Dr. Christina Smaczny

15.01.2013