Diagnosis of bronchopulmonary allergic aspergillosis

Diagnosis is based on a complex of clinical, radiological, functional, laboratory and immunological data. Radiological changes in bronchopulmonary allergic aspergillosis are different. Most often, massive homogeneous non-segmental shadows are found with primary localization in the upper lobe of the lung; they tend to quickly move from one side to the other with relapses in the area of ​​the initial lesion. Shadows disappear faster than with bacterial and viral infections. In places of resorption of homogeneous shadows often (up to 77% of cases), shadows are detected in the form of two parallel lines directed from the root to the bronchi. In the presence of bronchiectasis, especially in the lower lobes, a bacterial infection can develop with irreversible damage to the lungs, the appearance of new shadows, and their appearance and destruction are not associated with increased sensitivity to A. fumigatus. Ovoid basal consolidations, and also big ring-shaped shadows similar to caverns can be observed. With obstruction of the bronchus with a mucous plug, atelectasis of a segment, lobe, or total collapse of the lung develops. In the late stage of bronchopulmonary allergic aspergillosis, wrinkling of the upper lobe with a shift (pulling) of the root of the lung is noted.

Bronchography reveals cylindrical or saccular bronchiectases of the proximal bronchi with normal peripheral filling. These changes are localized in the area of ​​the previous pulmonary shadows.
In the sputum of most patients, mycelium of the fungus is found. However, this does not serve as an absolute diagnostic criterion, since the mycelium may not be detected in patients with bronchopulmonary allergic aspergillosis during the infiltration period, but it can be detected in healthy individuals after inhalation of the fungus that did not cause the development of the disease. In some cases, repeated sputum tests are negative, in others, patients “cough” bronchial tubes. In the peripheral blood, eosinophilia is noted (1000-3000 in 1 mm3). In the blood serum, the concentration of total immunoglobulin E is increased, which can reach 20,000 IU in 1 ml with relatively moderate eosinophilia. An increase in the content of immunoglobulin E precedes a relapse of the disease, and during exacerbation it is combined with the appearance of new pulmonary infiltrates and eosinophilia. A serial study of the content of immunoglobulin E helps assess the course of the disease. In addition, there is a high concentration of total immunoglobulin G, especially the fraction of immunoglobulin G1, in comparison with immunoglobulin G2, immunoglobulin G3, immunoglobulin G4 (the highest level is detected in the most acute cases). In 91% of patients, using antigen protein extract at a concentration of 10 mg / ml, precipitating antibodies related to immunoglobulin G are detected. In most patients with bronchopulmonary allergic aspergillosis, precipitating antibodies to Candida albicans were found.

Functional disorders of the respiratory system are characterized by a predominance of the obstructive component, there may be elements of restrictive changes.

Skin tests with a protein fraction of A. fumigatus reveal positive reactions of two types: immediate erythematous (positive in a quarter of patients with bronchopulmonary allergic aspergillosis); and late erythematic-infiltrative reactions, such as the Arthus phenomenon, developing 3-4 hours after antigen administration , reaching a maximum after 8 hours and resolving after 24 hours. The severity of the skin response depends on the test technique and the type of antigenic preparation. An intradermal test (1-10 mg / ml of the protein fraction of A. fumigatus) causes GNT and HRT in almost all patients with bronchopulmonary allergic aspergillosis.
Serum specific antibodies belonging to the class of immunoglobulin G are found in 2/3 of patients with bronchopulmonary allergic aspergillosis and are not an absolute diagnostic criterion (3% of healthy individuals, 12 patients with bronchial atopic asthma, 27% of patients with allergic exogenous bronchioalveolitis, all patients with aspergilloma). RBTL and the leukocyte migration inhibition test with A. fumigatus antigens are positive and to some extent correlate with the activity of the disease.

Allergic diagnostic tests provocative inhaled with A. fumigatus antigens reveal two types of bronchial reaction similar to the skin response: immediate (shortness of breath, rapid fall of FVC1) and delayed (shortness of breath, fever, leukocytosis for many hours). Testing is unsafe. The main criteria for the diagnosis of bronchopulmonary allergic aspergillosis are: shortness of breath, bronchospasm, cough with sputum, chest pain, fever, eosinophilia of blood and sputum, migratory pulmonary infiltrates, positive immediate and late skin tests with A. fumigatus antigens, the presence of precipitins to A. fumigatus, significantly increased levels of total immunoglobulin E, the detection of antibodies related to immunoglobulins E and immunoglobulins G in the blood serum, ventilation disorders are obstructive in the early stages and are restrictive e in later, poor reversibility of bronchoconstriction under the influence of bronchodilators. With the development of bronchopulmonary allergic aspergillosis with asthma, bronchial steroid-dependent, worsening of well-being, chills, myalgia, productive cough, respiratory failure may occur. Positive skin tests for A. fumigatus antigen appear, the level of total immunoglobulin E rises, persistent infiltrative changes are detected in the lungs. In other cases, the clinical symptoms of bronchopulmonary allergic aspergillosis are masked by glucocorticosteroid therapy and the disease is detected only by laboratory and immunological methods. 

local_offerevent_note October 31, 2019

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