Causes of ABPA

Question

Dear expert team,
I (CF, 26, female, FEV1 about 65%) would like to ask you for your opinion concerning an ABPA (allergic bronchopulmonary aspergillosis).
Already in March 2012 I was suspected to have an ABPA, as the typical antibiotic drugs did not help for the symptoms of an infection, however, cortisone and itraconazole helped. Blood values, sputum and x-ray were however never totally unambiguous. In July 2013 I was able to stop cortisone completely again without any worsening.
Now I stayed at relatives in a flat in an old building with humid walls for three nights at the end of December 2013. During the time there, I did not realize a worsening, also because I was still quite fit due to an i.v. therapy four weeks before. Four days after leaving the apartment I started to have again symptoms of an infection with much, however very light sputum, whereby also two members of the family had a cold.
As the situation did not improve, I got cefaclor at the CF center at the beginning of January 2014, that however did not really help, either. Only after taking 30mg of cortisone for three days it suddenly got better.
In the middle of February stronger cough started again and after another week I got hyperinflation and narrowing in the lung, again with much, however light sputum. It came finally to an acute orthopnea and 12 days of hospital stay with tobramycin, cefuroxim and 50mg cortisone i.v. as well as itraconazole. The sputum showed masses of Staphylococcus aureus, however no Aspergillus, the x-ray of the thorax was not markedly worse and the CRP low. However in the blood there were signs that ABPA played a role, however not really unambiguously.
As I would now like to find the reason for the relapse, I would like to know if you would consider a correlation to the stay in the humid apartment in December possible. Should I have noticed a worsening directly in the humid apartment or is it possible that the symptoms occur only after such a long period of time?
In my own apartment I checked the humidity of the air in all rooms and it is about 50%, what is normal according to my research and the formation of mould fungi would reportedly only occur over 60% air humidity.
To be on the safe side I got rid of all potted flowers that need much water. Are cactuses, that only get water once a week and are otherwise dry also a source of danger?
Should I have checked or avoid anything else inside or outside of the apartment? I take the garbage outside always immediately.
How does oneself react most reasonably in a situation of acute dyspnea, that has been caused by ABPA? Can one do anything else rather than sitting upright?
Are there any drugs or sprays that one could take? Salbutmol as a spray did unfortunately not have any effect.
Many thanks in advance,
Best regards,
S.

Answer

Hello dear questioner,
from your request, we can extract even several questions on the topic ABPA:
1- You want to know, if there could be a relation between your airway complaints and the stay in a humid appartment?
2- You ask us, if you should directly feel a worsening in the humid appartment or if it would be possible, that the symptoms may occur much later after having left the appartment?
3- You want to know, if cactuses, that are only watered once a week and stay otherwise in dry earth, could also be a source of danger for Aspergillus fumigatus?
4- You ask us, what else you could pay attention to in your appartment and what you should avoid concerning your ABPA?
5- How you should behave in an acute situation of dyspnea (here caused by ABPA)? (apart from sitting apart) and
6- if there are any effective drugs/sprays for such a situation? (hereby you emphazise, that salbutamol did not show any effect in your case).

Before I will answer your questions, I have to point out shortly, that we do not give medical treatment via the Internet, however can only give information. Our answers can help you anyway to have a talk with your CF physician in charge in order to get your questions answered concretely for you personally.
To 1-
Patients with ABPA develop asthmatic complaints if the fungus Aspergillus fumigatus is inhaled. In humid appartments the probability of finding Aspergillus fumigatus is very high, so that airway complaints in people with sensitization to the fungus can indeed occur. In case of ABPA, a sensitization on Aspergillus fumigatus is present.
To 2-
Patients with an active ABPA or an ABPA in their former history are sensitized to Aspergillus fumigatus and can in case of contact with the fungus directly or also shortly after develop asthmatic complaints.
To 3-
Potted flowers are always a potential danger for the development of mould fungi in the earth. Humid earth of plants is more predestined for this than this is the case with dry earth (cactuses).
However, it can not be excluded. In this context, astmatic patients with ABPA are discouraged from having potted flowers, especially in the sleeping room.
To 4-
In case of ABPA and bronchial asthma one has to pay attention that no mould fungus is developing in the appartment. Hereby the natural human sense helps to recognize situations that are related to the development of mould fungi. Apart from the by you already mentioned humid appartments, potted plants and garbage, additionally, for example, insufficient airing of the rooms (especially bathrooms), air-humidifiers, aquariums, tooth brushes, food and everything, where humid, warm and a lack of air come together may favor the development of mould fungi. Especially one has to pay attention to the cleanness of the inhalation device (single parts of the nebulizer have always to dry out well after disinfection!)
To 5- and 6-
In case of bronchial asthma patients, as well as of ABPA patients, the behaviour in case of actue dyspnea should be trained. You should absolutely talk about this to your CF physician in charge. The contents of the training comprise i.a. that it is important to have a sitting position, to use respective breathing techniques ("pursed-lip breathing"), to inhale a bronchial dilating drug (spray or humid Inhalation), call for help. Which drug should be used the best in your case of emergency can only be answered by your physician, who knows you and your results well.
I hope to have helped you a bit with my remarks.
Best regards,
Dr. med. Christina Smaczny

12.05.2014