대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Allegeric Bronchopulmonary Aspergillosis (ABPA)

Radiologic Findings

Thin-section CT scans show bronchiectasis, bronchial wall thickening, mucoid impaction, and subpleural centrilobular nodules.

Brief Review

Pulmonary disorders associated with hypersensitivity to fungus include ABPA, extrinsic asthma, extrinsic allergic alveolitis. Two latter conditions occur much less frequently than ABPA.
ABPA occurs almost exclusively in asthmatic patients.
Pathologically, the central bronchi are distended with thick mucus, admixed with cellular debris and eosinophils. The bronchial wall shows inflammatory cell infiltrate without evidence of fungal invasion. An eosinophilic pneumonia may be seen in the surrounding lung parenchyma (1).
Recently, it has been demonstrated that Aspergillus fumigatus releases a chymotrypsin-like proteinase which causes direct epithelial cell damage (2).
Patients have symptoms including wheezing, fever, cough, pleuritic pain, and expectoration of typical mucus plugs.
On thin-section CT, the presence of proximal saccular bronchiectasis is considered virtually pathognomonic for ABPA.
Impacted bronchi may appear as gloved finger, Y, V, toothpaste-like opacity, which may be transient or remain stable for months. Mucoid impaction is commonly seen in patients with cystic fibrosis. In one study of 100 cases of cystic fibrosis, approximately 10% of patients had ABPA (3).
Among major criteria for diagnosis of ABPA including asthma, peripheral eosinophilia, proximal bronchiectasis, pulmonary infiltrates, elevated serum IgE levels, IgG precipitins and immediate skin test reactivity to Aspergillus antigens, only proximal bronchiectasis is considered specific.
The diagnosis is certain if all seven criteria are present and still very likely if six of seven are present.
In one study (3), cylindrical bronchiectasis was the only type found in the non-ABPA asthmatics, whereas more severe bronchiectatic changes were detected in patient with ABPA and the finding of bronchiectasis was thought to represent advanced disease which mandates aggressive corticosteroid therapy.

References

1. Fraser RG, Pare JAP, Pare PD, Fraser RS, Genereux GP. Infectious disease of the lungs. In: Fraser RG, ed. Diagnosis of Disease of the chest. 3rd ed. Philadelphia, Pa: Saunders, 1989;996-1007

2. Robinson BW, Venaille TJ, Mendis AH, McAleer R. Allergens as proteinase: an Aspergillus fumigatus proteinase directly induces human epithelial cell detachment. J Allergy Clin Immunol 1990; 86:726-731

3. Neeld DA, Goodman LR, Gurney JW, Greenberger PA, Fink JN. Computerized tomography in the evaluation of allergic bronchopulmonary aspergillosis. Am Rev Respir Dis 1990; 142:1200-1205

Keywords

Airway, Lung, Airway disease including COPD, Fungal infection,