1. Clinical and radiological presentation and diagnosis
David W. Denning
National Aspergillosis Centre
University Hospital South Manchester
[Wythenshawe Hospital]
University of Manchester

2. The National Aspergillosis Centre
new patients with aspergillosis referred annually

3. CLASSIFICATION OF ASPERGILLOSIS
Invasive aspergillosis
Acute (<1 month course)
Subacute/chronic necrotising (1-3 months)
Airways/nasal exposure to airborne Aspergillus
Chronic aspergillosis (>3 months)
Chronic cavitary pulmonary
Aspergilloma of lung
Chronic fibrosing pulmonary
Chronic invasive sinusitis
Maxillary (sinus) aspergilloma
Persistence without disease - colonisation of the airways or nose/sinuses
Allergic
Allergic bronchopulmonary (ABPA)
Extrinsic allergic (broncho)alveolitis (EAA)
Asthma with fungal sensitisation
Allergic Aspergillus sinusitis (eosinophilic fungal rhinosinusitis)
Exposure to individual Aspergillus spores or conidia is almost constant. If eradicated immediately, as is usual in normal people, no disease results. If colonisation occurs, it may be short or long term. The pattern of disease is mostly determined by the host group (see next slide), with probably a component of the inoculum size contributing to invasive disease.
However chronic disease if usually seen in patients with apparently normal immune systems. 3

4. After Casadevall & Pirofski, Infect Immun 1999;67:3703
Interaction of Aspergillus with the host A unique microbial-host interaction
Acute IA
ABPA
Severe asthma with
fungal sensitisation
Allergic sinusitis
Subacute IA
Frequency of aspergillosis
Frequency of aspergillosis
Aspergilloma
Chronic pulmonary
Immune dysfunction
Immune hyperactivity .
After Casadevall & Pirofski, Infect Immun 1999;67:3703

5. Size of Aspergillus disease problem globally
Over 200,000 patients develop IA annually. Key groups include ~10% of acute leukaemia (30,000) and stem cell and other transplants (7,500) and 1.3% of COPD patients admitted to hospital (60,000 IA cases).
Chronic pulmonary aspergillosis after TB – 1.1M cases prevalence
Chronic pulmonary aspergillosis total - ~3M
Asthma 197M in adults, of which ~10-20% severe, UK and USA have very high prevalence rates 5

6. How common is ABPA in asthma?
10/1390 (0.72%)
9/255 (3.5%)
6/264 (2.3%)
Donnelly, Irish J Med Sci 1991;160:288; Eaton, Chest 2000;118:66; Al-Mobeireek, Resp Med 2001;98:341

7. Size of Aspergillus disease problem globally
Over 200,000 patients develop IA annually. Key groups include ~10% of acute leukaemia (30,000) and stem cell and other transplants (7,500) and 1.3% of COPD patients admitted to hospital (60,000 IA cases).
Chronic pulmonary aspergillosis after TB – 1.1M cases prevalence
Chronic pulmonary aspergillosis total - ~3M
Asthma 197M in adults, of which ~10-20% severe, UK and USA have very high prevalence rates
Allergic bronchopulmonary aspergillosis in asthma - ~4M worldwide (2.1% of adults referred with asthma)
Severe asthma with fungal sensitisation - ~6M worldwide (33% of 10% (severe only)) 7

8. Human genetic influence on disease expression
Interaction of Aspergillus with the host A unique microbial-host interaction
Human genetic influence on disease expression
Acute invasive
aspergillosis
ABPA
Severe asthma with
fungal sensitisation
Allergic sinusitis
Subacute invasive
aspergillosis
Frequency of aspergillosis
Frequency of aspergillosis
Aspergilloma
Chronic pulmonary
aspergillosis
Immune dysfunction
Immune hyperactivity .
After Casadevall & Pirofski, Infect Immun 1999;67:3703

9. Chronic Pulmonary Aspergillosis

10. Common symptoms Common symptoms Cough, usually productive
Shortness of breath
Weight loss
Tiredness
Coughing up blood
Chest ache / discomfort
Occasionally
Fever
Severe chest pain from rib fracture
Additional chest infections
Angina and heart attacks (chronic inflammation)

11. Underlying diseases
9 patients with chronic cavitary pulmonary aspergillosis 15 with chronic necrotising pulmonary aspergillosis
Camuset et al, Chest 2007:131:1435

12. Underlying diseases - CPA
Classical tuberculosis *
Atypical tuberculosis *
Allergic bronchopulmonary aspergillosis *
Lung cancer survivor *
Pneumothorax *
COPD/emphysema *
Sarcoidosis (stage II/III) *
Rheumatoid arthritis
Thoracic surgery
Asthma
Chest radiotherapy
None
* Common
Smith, ISHAM 2009 12

13. Chronic pulmonary aspergillosis – pre-existing disease
Prior pulmonary disease esp:
Atypical mycobacteria pulmonary infection
Sarcoidosis
Tuberculosis
Recurrent pneumothorax
Prior pulmonary surgery
ABPA
Denning DW et al, Clin Infect Dis 2003; 37:S265

14. Frequency of chronic pulmonary aspergillosis after TB
~10% of all cases of pulmonary TB get CPA
Anonymous. Tubercle 1970;51:227

15. Before After treatment
Acute tuberculosis
Cavities
Cavities
Before After treatment
Cavities
No cavities
Lee, Eur J Radiol 2008; 67:100;

16. Chronic pulmonary aspergillosis
Infection of the lung by Aspergillus
Single fungal ball or aspergilloma
in a pre-existing cavity
Exposure to individual Aspergillus spores or conidia is almost constant. If eradicated immediately, as is usual in normal people, no disease results. If colonisation occurs, it may be short or long term. The pattern of disease is mostly determined by the host group (see next slide), with probably a component of the inoculum size contributing to invasive disease.
However chronic disease if usually seen in patients with apparently normal immune systems.

17. Simple (single) aspergilloma
Patient RK
Haempotysis, nil else
Positive Aspergillus antibodies in blood
Lobectomy
Wythenshawe Hospital

18. Aspergillomas from 2 patients
Wythenshawe Hospital; Severo on

19. Histology of an aspergilloma
Severo on

20. Aspergillus fumigatus

21. Aspergilloma due to A. niger and oxalosis
Renal oxalosis
Oxalate crystals in wall of the aspergilloma
Severo on

22. Early Aspergillus infection of a pulmonary cavity – ‘pre-aspergilloma’
Orderly hyphal growth on the inside of the cavity
Aspergillus growth on the surface of a pulmonary cavity
Severo on

23. ‘Multicavity’ disease is the hallmark of chronic cavitary pulmonary aspergillosis (CCPA)
Wythenshawe Hospital

24. Aspergilloma #3 – spatially ordered isolates from multiple cavities
Bowyer et al, unpublished

25. Aspergillus precipitins (Aspergillus antibody (IgG) ) in blood
Patient 2
blood
Patient 3
blood
Patient 1
blood
Aspergillus extract
Patient 6
blood
Patient 4
blood
Patient 5
blood
Severo on

26. Aspergillus IgG serology
Baxter, AAA 2010;Abstr 51 26

27. Chronic pulmonary aspergillosis - serology
All 18 patients had positive Aspergillus precipitins (1+-4+)
All 18 patients had elevated inflammatory markers, CRP, PV and / or ESR
May have elevated total IgE and Aspergillus specific IgE (RAST)
Only 40% have a positive sputum culture
Denning DW et al, Clin Infect Dis 2003; 37:S265

28. Chronic pulmonary aspergillosis
Infection of the lung by Aspergillus
Single fungal ball or aspergilloma
in a pre-existing cavity
Chronic cavitary pulmonary aspergillosis
+/- fungal ball
Exposure to individual Aspergillus spores or conidia is almost constant. If eradicated immediately, as is usual in normal people, no disease results. If colonisation occurs, it may be short or long term. The pattern of disease is mostly determined by the host group (see next slide), with probably a component of the inoculum size contributing to invasive disease.
However chronic disease if usually seen in patients with apparently normal immune systems.

29. Chronic cavitary pulmonary aspergillosis – CT reconstruction
Wythenshawe Hospital

30. Chronic cavitary pulmonary aspergillosis (CCPA) – sputum production
Aspergillus cultures positive in CCPA in 10-40% of cases only
Wythenshawe Hospital

31. ‘Multicavity’ disease is the hallmark of chronic cavitary pulmonary aspergillosis (CCPA)
Wythenshawe Hospital

32. Chronic cavitary pulmonary aspergillosis (CCPA) – haemoptysis
Wythenshawe Hospital

33. Chronic Cavitary Pulmonary Aspergillosis Normal 30 year female smoker
Patient JA
Jan 2001

34. Chronic Cavitary Pulmonary Aspergillosis
Patient JA
April 2003

35. Multifocal cavities with aspergillomas – unrecognised phenotype
Wythenshawe Hospital

36. 18F-FDG PET positive pulmonary nodules in aspergillosis – a differential diagnosis of lung cancer
10 patients
Presentations like lung cancer
1 subacute IPA
1 ABPA
1 aspergilloma
7 CPA
Aspergillus IgG
28 ->200 mg/L
All positive on histology
Baxter, Thorax 2011

37. CLASSIFICATION OF ASPERGILLOSIS
Invasive aspergillosis
Acute (<1 month course)
Subacute/chronic necrotising (1-3 months)
Airways/nasal exposure to airborne Aspergillus
Chronic aspergillosis (>3 months)
Chronic cavitary pulmonary
Aspergilloma of lung
Chronic fibrosing pulmonary
Chronic invasive sinusitis
Maxillary (sinus) aspergilloma
Persistence without disease - colonisation of the airways or nose/sinuses
Allergic
Allergic bronchopulmonary (ABPA)
Extrinsic allergic (broncho)alveolitis (EAA)
Asthma with fungal sensitisation
Allergic Aspergillus sinusitis (eosinophilic fungal rhinosinusitis)
Exposure to individual Aspergillus spores or conidia is almost constant. If eradicated immediately, as is usual in normal people, no disease results. If colonisation occurs, it may be short or long term. The pattern of disease is mostly determined by the host group (see next slide), with probably a component of the inoculum size contributing to invasive disease.
However chronic disease if usually seen in patients with apparently normal immune systems. 37

38. Allergic Bronchopulmonary Aspergillosis

39. ABPA – Diagnostic clues
Asthma/CF not well controlled
History of ‘pneumonia’
History of coughing up plugs, or paroxysms of coughing that clear when chest clears
Central bronchiectasis on CT scan, or mucoid impaction
Eosinophilia
Rare cases in non-asthmatics, non-CF patients

40. Asthma – variable airflow obstruction
Inhaled steroids
Patient SY, Aspergillus Website

41. Proposed new criteria for ABPA
Serum IgE >1000 IU/mL
Asthma OR CF
Airway obstruction (ie CT scan/bronchoscopy) by or production of mucus plugs containing hyphae
Which fungus?
Fungal sensitisation (IgE or SPT) and/or fungus detected in respiratory secretions
Knutsen et al, AAAAI Task Force on Fungus and Asthma 41

42. ABPA - March – doing well
FEV1 = 3.00
Aspergillus IgE = 31
IgE = 1900.
No treatment

43. September – episode of pneumonia
FEV1 = 1.6.
IgE = 3000
Aspergillus IgE = 52.5.
Exacerbation of ABPA

44. Exacerbation of ABPA Patient AL
January 2011
June 2011
May 2010

45. Exacerbation of ABPA Patient AL
September 2011

46. Mucoid impaction due to ABPA

47. Mucoid impaction due to ABPA

48. Sputum in ABPA

49. ABPA – bronchoscopy views showing mucous plugging

50. A. fumigatus in BAL and in bronchial tissue in ABPA

51. Severe Asthma and Fungal Sensitisation

52. Fungal exposure in asthmatics is related to:
Life-threatening asthmatic attacks (ie thunderstorm asthma)
Severe asthma and hospital admission
Increased wheezing and symptoms
Loss of medication control
Allergic bronchopulmonary mycosis
Eosinophilic fungal rhinosinusitis
O'Hollaren, N Engl J Med 1991; 324: 359; and many others

53. Airborne fungal fragments
Diffusing allergen leeching out of fungus in contact with liquid
Green et al, J Allergy Clin Immunol 2005;115:1043

54. Genomic analysis of allergens
Bowyer et al, BMC Genomics 2006;7:251

55. Severe asthma and mould senstivity – Alternaria and Cladosporium
Mild asthma – 564 (50%)
Moderate asthma – 333 (29%)
Severe asthma – 235 (21%)
Zureik et al, Br Med J 2002;325:411

56. Mean sensitization score (mm)
Non-Mould allergens No
Hospital
Admission
Single
Multiple
Admissions
20.0
Mould allergens No
Hospital
Admission
Single
Multiple
Admissions
P= <0.0001
17.5
15.0
12.5
Mean sensitization score (mm)
(Mean and 95% CI)
10.0
7.5
5.0
2.5
0.0
O’Driscoll et al, BMC Pulmonary Medicine 2005;5:4

57. Colonisation in ‘normal’ lungs
22 of 30 (73%) grew a fungus in both lung samples taken
10/30 (33%) grew >1 species
Lass-Florl et al, Br J Haematol 1999;104:745

58. Asthma and Aspergillus
79 adult asthmatics and 14 controls
Patients sensitised to A. fumigatus compared with non-sensitised asthmatics had:
lower lung function (% pred. FEV1 68% vs 88% p < 0.05),
more bronchiectasis (68% versus 35% p < 0.05) and more sputum neutrophils (80.9% vs 49.5% p < 0.01).
Fairs et al, Am J Respir Crit Care Med 2010; July 16

59. Severe asthma and aspergillosis in ICU
57 of 357 (16%) admitted ICU with acute asthma
Compared with 755 outpatients with asthma
Aspergillus skin prick test used to screen for aspergillus hypersensitivity, if positive IgE etc for ABPA checked
Aspergillus positive ABPA
Asthma in ICU /57 (51%) /57 (39%)
Outpatient asthma 90/755 (39%) /755 (21%)
P value
Agarwal et al, Mycoses 2009 Jan 24th

60. Severe asthma with invasive aspergillosis
Felton et al Chest 2010;137:724

61. Severe asthma with fungal sensitisation (SAFS)
Criteria for diagnosis
Severe asthma (BTS step 4 or 5)
AND
RAST (IgE) positive for any fungus OR
Skin prick test positive for any fungus
Exclude ABPA (ie total IgE <1,000 iu/mL)
Denning et al, Eur Resp J 2006; 27;27:615

62. Comparison of ABPA and SAFS serology
ABPA results normal range date 1 date 2
Patient 1 2
SAFS results

63. Skin prick testing – example of SAFS result
Cladosporium +ve
O’Driscoll, unpublished

64. >23% discordant results
Fungal sensitisation in severe asthma – skin prick test or RAST for diagnosis?
N= 121 patients screened
100% }
>23% discordant results
50% 43 34 10 13
SPT + RAST
both positive
SPT positive
RAST negative
SPT negative
RAST positive
SPT negative
RAST negative
O’Driscoll et al, Clin Exp Allergy. In press

65. Sensitisation to one or more fungi
Fungal sensitisation in severe asthma – number sensitised to one or more fungi
N = 40
13 sensitised to only Aspergillus
8 to Candida
3 to Trichophyton
3 to Penicillium
1 to Alternaria
1 to Cladosporium
N = 20 29 11 11 12 7 7 3
Sensitisation to one or more fungi
O’Driscoll et al, Clin Exp Allergy. In press

66. Distinguishing different forms of aspergillosis
Disease group
CCPA
ABPA + CCPA
ABPA
SAFS n
116 16 98 52
Median serum IgE level (IQR)
99.8 ( )
(n=107)
2739
( )
(n=16)
2300
( )
(n=97)
370
( )
(n=52)
Aspergillus specific IgG
93.6% (103/110)
81.3% (13/16)
65.4% (53/81)
35.9% (14/39)
Positive fungal culture
25% (29/116)
25.0% (4/16)
23.5% (23/98)
21.2% (11/52)
Positive specific IgE
Positive SPT
Mixed mould
N/T
88.9% (8/9)
90.9% (20/30)
100% (2/2)
A. fumigatus
37.7% (40/106)
93.8% (15/16)
96.9% (94/97)
78.8% (41/52)
Alternaria alternata
10.0% (1/10)
100% (10/10)
77.5% (55/71)
32.5% (13/40)
47.4% (9/19)
C. albicans
33.3% (3/9)
90.0% (9/10)
81.4% (57/70)
37.5% (15/25)
52.6% (10/19)
Cladosporium herbarum
20.0% (2/10)
80.0% (8/10)
70.4% (50/71)
24.4% (10/41)
35.5% (6/17)
Penicillium chrysogenum
27.3% (3/11)
85.3% (58/68)
30.0% (12/40)
43.8% (7/16)
Trichophyton mentagrophyte
33.3% (2/6)
100% (3/3)
65.2% (30/46)
25.0% (9/36)
23.1% (3/13)

67. Distinguishing different forms of aspergillosis
Disease group
CCPA
ABPA + CCPA
ABPA
SAFS n
116 16 98 52
Median serum IgE level (IQR)
99.8 ( )
(n=107)
2739
( )
(n=16)
2300
( )
(n=97)
370
( )
(n=52)
Aspergillus specific IgG
93.6% (103/110)
81.3% (13/16)
65.4% (53/81)
35.9% (14/39)
Positive fungal culture
25% (29/116)
25.0% (4/16)
23.5% (23/98)
21.2% (11/52)
Positive specific IgE
Positive SPT
Mixed mould
N/T
88.9% (8/9)
90.9% (20/30)
100% (2/2)
A. fumigatus
37.7% (40/106)
93.8% (15/16)
96.9% (94/97)
78.8% (41/52)
Alternaria alternata
10.0% (1/10)
100% (10/10)
77.5% (55/71)
32.5% (13/40)
47.4% (9/19)
C. albicans
33.3% (3/9)
90.0% (9/10)
81.4% (57/70)
37.5% (15/25)
52.6% (10/19)
Cladosporium herbarum
20.0% (2/10)
80.0% (8/10)
70.4% (50/71)
24.4% (10/41)
35.5% (6/17)
Penicillium chrysogenum
27.3% (3/11)
85.3% (58/68)
30.0% (12/40)
43.8% (7/16)
Trichophyton mentagrophyte
33.3% (2/6)
100% (3/3)
65.2% (30/46)
25.0% (9/36)
23.1% (3/13)

68. Conceptual framework for CPA and IA
Immune function
Hyphal load in tissue
Normal
Massive
Chronic inflammation and fibrosis
Vascular invasion, necrosis, dissemination
Granulomas, acute inflammation, central necrosis
Aspergilloma - CCPA - CNPA/subacute IPA - acute IPA

69. Alternative Aspergillus diagnoses
Aspergillus bronchitis
Obstructing bronchial aspergillosis
Invasive Aspergillus tracheobronchitis
Community acquired Aspergillus pneumonia
Sub-acute invasive pulmonary aspergillosis (often called chronic necrotising pulmonary aspergillosis or CNPA)
Extrinsic allergic (bronchiol)alveolitis (EAA)
Aspergillus empyema

70. 6th Jan
24th Feb
Arendrup, Scand J Infect Dis 2006:38:945

71. Obstructing bronchial aspergillosis
Patient ML
Pre-bronchscopy
Patient ML
After bronchoscopy
Denning et al, New Engl J Med 1991;324: 654

72. Subacute invasive pulmonary aspergillosis in AIDS
Patient HB
Day +14, CD4 cells 84/uL
Biopsy positive for Aspergillus
Sambatakou, Eur J Clin Microbiol Infect Dis 2005;24:628

73. Conclusions
CPA = 3 months of pulmonary cavitation or nodule +/- aspergilloma, with symptoms + Aspergillus IgG or precipitins positive
CPA patients almost all have an underlying diagnosis
ABPA = asthma (any severity) or cystic fibrosis + total IgE >1,000 + SPT or Aspergillus IgE positive.
SAFS = severe asthma + fungal SPT or IgE positive + total IgE <1,000
Some patients have overlap syndromes and more than 1 Aspergillus diagnosis