Epidemiology of ABPA

8/17/2019 Epidemiology of ABPA

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Epidemiology of allergic

bronchopulmonaryaspergillosis (ABPA)Dr Ritesh Agarwal MD, DM

A!P, !!P, AP"R, R!P(#lasg)

Associate Professor

Dept$ of Pulmonary Medicine

Postgraduate %nstitute of Medical Education and Research

!handigarh, %ndia


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!handigarh&


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Agenda Epidemiology of ABPA (in asthma)

!ommunity pre'alence of ABPA

Pre'alence in secondary care cohorts Pre'alence in tertiary care cohorts

#lobal (and %ndian) burden of ABPA

Peculiarities in the %ndian ABPA cohort


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ABPA ypersensiti'ity pulmonary disorder caused by immune

responses against Aspergillus fumigatus coloniing the

tracheobronchial tree of patients with asthma (and cystic

fibrosis)

&little or no tissue in'asion by the organism

Agarwal R, et al. Future Microbiol


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irst description *+ inson +- et al ./hora0 12345 67 816889

*" Patterson R et al .*ni' Mich Med !ent : 12;


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-hy so much interest> /he fact that the condition responds remar?ably to

glucocorticoid or aole therapy

Early detection and treatment may eliminate the ris? ofprogression to endstage fibrotic lung disease

Hoga !, et al. "e#i Re$%ir !rit !are Me&


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@ew diagnostic criteria for

ABPA Predisposing conditions

Bronchial asthma, cystic fibrosis

Obligatory criteria (both should be present)

/ype % Af s?in test positi'e or ele'ated Af %gE ($83 ?*AC)

Ele'ated total %gE le'els (1 %*Cm)

Other criteria (at least two of three)

Presence of Af precipitating (or %g#) antibodies in serum

Radiographic pulmonary opacities consistent with ABPA

Eosinophil count 3 cellsC in steroid naF'e patients (may be

historical)

Agarwal R, et al. !li ()% Allerg* 2013;43:8+0-


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/erminology Aspergillus sensitization Type 1 positive Aspergillus sin test or

A.fumigatus Ig! "#$%& '*

"erologic ABPA (ABPA") Meets the diagnostic criteria for ABPA but noabnormalities related to ABPA on !/ chest

ABPA with bronchiectasis(ABPAB)

Meets the diagnostic criteria for ABPA withpresence of bronchiectasis on !/ chest

"e'ere asthma with fungalsensitiation ("A")

"e'ere asthma, fungal sensitiation, %gE G1%*Cm


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%ncrease in the number of

cases of ABPA An increasing number of cases of ABPA ha'e been

reported in the last two decades

eightened physician awareness

-idespread a'ailability of commercial immunological

assays for the diagnosis of ABPA

%nitially, the disorder was thought to be rare in @orth

America, but subseHuent reports dispro'ed this myth ABPA truly has a global presence

"lai R, et al. A# Me& 1'6';47:306Hoe/e H, et al. !/e$t 1'73;63:177


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!linical presentation Although most patients with ABPA are diagnosed in the

third or fourth decade of life, there is no specific age or

gender predilection for its occurrence

E'en children and the elderly may be afflicted

amilial occurrence has been documented in up to 3I of

cases

Agarwal R, et al. o" e 2013; 8:e6110+"/a/ A, et al. A Allerg* A$t/#a ##uol


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!ommunity pre'alence Remains un?nown because of lac? of populationbased

studies

/he only population based data a'ailable is for Aspergillus sensitiation (@A@E", *nited "tates)

Pre'alence of Aspergillus sensitiation was found to be

;$=I using A$fumigatus specific %gE le'els

/his data is for the general population, howe'er we wantsimilar data for asthmatic patients in the general

population

ere , et al. Allerg* !li ##uol 200';124:


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Primary care cohort !urrently no data is a'ailable


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"econdary care seHuential

cohortuthor +ear Place Total

asth,atics-o$ with.P(/)

Benatar et al$ 12


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/ertiary care0tudy ountry Type of study Prevalence of .P in

asth,a (n-)!ampbell et al$ (12;=) *+ Retrospecti'e


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/ertiary care

Agarwal R, et al. t uberc ug i$

Pre'alence of ABPA in asthma

12 studies (2,454 asthma patients)


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ur e0perience Acti'e screening of asthmatics

226 asthmatics screened with Aspergillus s?in test

Aspergillus sensitiation 86< (8


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Burden of the disease "coping re'iew

128 million adults with asthma worldwide using #lobal %nitiati'e

Against Asthma (#%@A) calculations

Assuming o'erall pre'alence of ABPA as 4$3I (secondary carecohort pre'alence), the global burden of ABPA was =$< million

(range,1$=;$< million)

eig


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Burden of "A"

/he global burden of "A" is about ;$< million


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"tudies in this millennium

Agarwal R, et al. !li ()% Allerg* 2013;

Pre'alence is higher in the %ndian population compared to other populations

424C1


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Burden in %ndiaTotal population (2#11 Indian census) 1321#3&493&7% Adult %ndian population (N13y)


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Pre'alence in se'ere asthmaE'en higher pre'alence in se'ere acute asthma

%n a study of 36 consecuti'e patients with se'ere acute

asthma Pre'alence of Aspergillus sensitiation and ABPA7 31I

and 82I, respecti'ely

"ignificantly higher than our outpatient asthma group7

A" 8


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Epidemiologic

peculiarities in the%ndian ABPA cohort


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ighattenuation mucus

(AM) Pathognomonic finding of

ABPA

*ncommonly described

from other centers "een in

almost 4I of our patients

!ould be recognition bias or

could really represent a

different spectrum of ABPA

Patients with AM ha'e

se'erer immunological

findings compared to other

patients and are prone forrela ses

Agarwal R, et al. A# Roetgeol 2006; 186:

'04 Agarwal R,et al. !/e$t 2007; 132:1183-11'0


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ABPA in !PD %n %ndia, ABPA has been identified in conditions other

than asthma and cystic fibrosis


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ABPA in !PD %n a study of 4 consecuti'e !PD patients (and 1

healthy controls)

Aspergillus sensitiation was found in 16 (


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ABPA in pulmonary tuberculosis

related fibroca'itary disease

/ooria ", et al. t uberc ug i$ 2014:


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ABPA in pulmonary tuberculosis

related fibroca'itary disease !asecontrol study

3 consecuti'e symptomatic new referrals with P/B

related fibroca'itary disease (and 3 controls) A" was present in 1; (84I) cases

i'e (1I) patients met the criteria for diagnosis of ABPA

/ooria ", et al. t uberc ug i$ 2014:


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En'ironmental factors in ABPA Prospecti'e casecontrol Huestionnaire based study

i'ing conditions (home en'ironment, presence of

moisture in the walls, details of house type, presence ofseparate ?itchen), use of water coolers, type of fuel,

contact with farm, cattle and pets

44 subKects of asthma (18 and 22 Aspergillus

unsensitied and sensitied asthma respecti'ely) and 11 ABPA

Agarwal R, et al. ug &ia 2014; r


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En'ironmental factors in ABPA Aspergillus unsensitized

asth,a (n61#%)

Aspergillussensitized

asth,a (n699)

.P(n61#1)

Pvalue

Rural residence 3 (=


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#enetic predispositionInnate i,,unity"urfactant protein A4 genepolymorphisms

Mannosebinding lectin gene

polymorphisms/ollli?e receptor 2 genepolymorphisms

Adapti'e immunity

A associations

%nterleu?in = receptor alphapolymorphisms

%nterleu?in 18 polymorphisms

Interleuin 1# pro,oterpoly,orphis,s


/umor necrosis factorOpolymorphisms

/ransforming growth factorpolymorphisms

thers

!/R gene mutation!%/1 gene mutations



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#enetic predispositionInnate i,,unity"urfactant protein A4 genepolymorphisms

Mannosebinding lectin gene

polymorphisms/ollli?e receptor 2 genepolymorphisms

Adapti'e immunity

A associations

%nterleu?in = receptor alphapolymorphisms


Interleuin 1# pro,oterpoly,orphis,s


/umor necrosis factorOpolymorphisms

/ransforming growth factorpolymorphisms

thers

!/R gene mutation!%/1 gene mutations


@ot studied well in the %ndianPopulation


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"ummary ABPA has a global presence, significant burden and is far

more common than pre'iously thought

/he community pre'alence is not ?nown but thepre'alence is secondary care is about 4$3I

@eed for community data, which is difficult to obtain

Data from primary care cohort should be obtained that

would ser'e as a surrogate for community pre'alence


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/han? you


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-or?ing group on ABPA

:oin the %"AM ABPA

wor?ing group !ontact us at7

agarwal$riteshQpgimer$edu$in

arunalo?eQhotmail$com

da'id$denningQmanchester$ac$u?
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]

Epidemiology of ABPA

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