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Bronchopulmonary Aspergillosis Thorax: first published as 10.1136/thx.44.11.919 on 1 November 1989. Downloaded from Thorax 1989;44:919-924 Pulmonary eosinophilia with and without allergic bronchopulmonary aspergillosis B J CHAPMAN, S CAPEWELL, R GIBSON, A P GREENING, G K CROMPTON From the Respiratory Unit, Northern General Hospital, Edinburgh ABSTRACT Sixty five patients with pulmonary eosinophilia attending one respiratory unit were reviewed. All had fleeting radiographic abnormalities and peripheral blood eosinophil counts greater than 500 x 106/1. Eighteen had a single episode and 47 recurrent episodes during a median follow up period of 14 years. Thirty three patients had allergic bronchopulmonary aspergillosis on the basis of a positive skin test response to Aspergillusfumigatus, serum precipitins, or culture ofAfumigatus from sputum, or a combination of these. All but seven patients had asthma, six of the seven being in the group who did not have allergic bronchopulmonary aspergillosis. The patients with allergic bronchopulmonary aspergillosis were more often male and had a greater incidence ofasthma and an earlier age of onset of asthma than those without aspergillosis. The patients with aspergillosis had lower mean blood eosinophil counts and more episodes of pulmonary eosinophilia and more commonly had radiographic shadowing that suggested fibrosis or bronchiectasis (20 v 7). Pulmonary eosinophilia associated with allergic bronchopulmonary aspergillosis appears to be a distinct clinical syndrome resulting in greater permanent radiographic abnormality despite lower peripheral blood eosinophil counts. copyright. Introduction ated from secondary and tertiary referral centres, which makes it difficult to estimate the relative The term pulmonary eosinophilia describes a group of frequency of the various underlying conditions. The disorders in which transient radiographic lung differences between patients with and without allergic http://thorax.bmj.com/ shadows are associated with a raised blood eosinophil bronchopulmonary aspergillosis are not clear. We count.' Allergic bronchopulmonary aspergillosis is the therefore reviewed an unselected series ofpatients with most common cause of pulmonary eosinophilia in pulmonary eosinophilia attending a primary referral Britain.2 Pulmonary eosinophilia has also been unit during a 20 year period. described in association with other fungi,4 an increas- ing number of drugs,5 the systemic vasculitides,6' and Methods the hypereosinophilic syndrome.89 Most cases of with tropical pulmonary eosinophilia are allergic reactions Sixty five patients pulmonary eosinophilia on September 28, 2021 by guest. Protected to filarial infestations,'0 whereas various helminths attending the Northern General Hospital, Edinburgh, have been implicated in more temperate latitudes." during 1966-86 were identified. All had evidence of About 20% of cases of pulmonary eosinophilia in transient pulmonary shadowing associated with a Britain are unexplained and labelled cryptogenic. " " peripheral blood eosinophil count exceeding Recommended classifications have their limitations, 500 x 106/1. The patients' medical records were whether based on clinical features,'4 aetiology," 15 16 or reviewed for evidence of asthma, atopy, hypersen- anatomical and pathological features." sitivity to Aspergillus fwnigatus, clinical features There are many published studies on allergic associated with episodes of pulmonary eosinophilia, bronchopulmonary aspergillosis, but fewer on pulmonary function tests, corticosteroid treatment, pulmonary eosinophilia.312 Most studies have origin- radiographic features, and possible aetiological factors other than A fumigatus. Patients with asper- gilloma were excluded. Address for reprint requests: Dr G K Crompton, Respiratory Unit, Patients were considered to be asthmatic ifthere was Northern General Hospital, Edinburgh, EH5 2DQ. evidence of airflow obstruction (FEV, < 70% Accepted 14 August 1989 predicted) and more than 15% variation in FEV, over 919 Thorax: first published as 10.1136/thx.44.11.919 on 1 November 1989. Downloaded from 920 Chapman, Capewell, Gibson, Greening, Crompton a short period either spontaneously or in response to Table 1 Number ofpositive results ofAspergillusfumigatus bronchodilator treatment. Atopy was defined by two tests in the groups with and without allergic or more positive skinprick test responses to common bronchopulmonary aspergillosis (ABPA) allergens (grass pollens, shrubs, tree mix, house dust, house dust mites, feathers, dog hair, and cat fur), ABPA Non-ABPA excluding Aspergillus species (Bencard). A fumigatus (n= 33) (n = 32) precipitins were identified by an Agar-gel double Immediate skin test 33 8 diffusion technique using A antigens 1 and Serum precipitins 31 0 fwnigatus Sputum culture 24 3 11 (Bencard). A diagnosis of allergic broncho- pulmonary aspergillosis was made if an immediate skinprick testoresponse to A was fumigatus positive, had the Churg-Strauss syndrome and one a and if serum precipitins to Afumigatus were present or hypereosinophilia like syndrome. Two patients had Afumigatus was cultured from sputum. Bronchiectasis rheumatoid arthritis and two pernicious anaemia and was identified by bronchography (nine patients) or by one had had sarcoidosis. that or radiographic shadowing suggested fibrosis Fifty eight patients were asthmatic and seven non- bronchiectasis with (five) or without (13) a history of asthmatic. The asthmatic patients had been followed chronic cough and sputum. up for longer than the non-asthmatic patients (median were x2 test The results analysed by the with Yates's 14-5 v 2 years; p < 0-05). Six of the seven non- correction and Wilcoxon's rank sum test for unpaired asthmatic patients did not have aspergillosis; in five of data.'8 the seven patients episodes of aspergillosis were associated with systemic features (see below). In six Results patients pulmonary eosinophilia preceded the onset of asthma (interval 1-11, median 9 years). Sixty five patients (27 male, 38 female) were identified. Patients with allergic bronchopulmonary asper- There were 247 recorded episodes of pulmonary gillosis were more frequently asthmatic, atopic, and eosinophilia, 18 patients having single and 47 patients male than those without aspergillosis and had lower recurrent episodes. The median age at the time of the blood eosinophil counts during episodes ofpulmonarycopyright. first episode was 39 (range 12-78) years and the eosinophilia (table 3). The onset ofasthma occurred at median follow up period 14 (range 1-31) years. an earlier age in the group with aspergillosis (median Thirty three patients met the criteria for allergic 7.5 v 30 5 years; p < 0-01) but age at the first bronchopulmonary aspergillosis (table 1). The documented episode of pulmonary eosinophilia was remaining 32 were labelled "non-allergic broncho- similar for the two groups (fig 1). The interval between pulmonary aspergillosis." Eight of the 32 had an onset of asthma and onset of pulmonary eosinophilia http://thorax.bmj.com/ isolated positive skin test response to A fumigatus was therefore greater in the patients with allergic (table 2). There was no evidence of drug induced bronchopulmonary aspergillosis (median 19 v 11 pulmonary eosinophilia in any subject. Faecal years; p < 0-05). Patients with aspergillosis also had specimens in 10 patients were negative for cysts, ova, more episodes of pulmonary eosinophilia (median 5 v and parasites. One of the 32 non-aspergillosis patients 2; p < 0-01: fig 2) and a longer duration of follow up Table 2 Significance ofa positive skin test response to Aspergillusfumigatus in patients with pulmonary eosinophilia: comparison ofclinical and investigativefeatures with allergic and bronchopulmonary aspergillosis (ABPA) "definite" on September 28, 2021 by guest. Protected non-ABPA patients (see text) Non-ABPA ABPA Positive skin response Definite non-ABPA (n = 33) alone (n = 8) (n = 24) Aspergi.lusfumigatus Skin test positive 33 8 0 Serum precipitin positive 31 0 0 Sputum culture positive 24 0 3 Asthmatic 32 7 19 Median (range) age of onset of asthma (y) 7-5 (1-61) 29 (2-49) 31 (2-69) Median (range) age of onset of pulmonary eosinophilia(y) 38 (14-78) 41 (22-65) 39 (13-67) Maximum blood eosinophil count during episodes x I0'/I (group mean (SD)) 2290 (3584) 4774 (3681) 3109 (2767) Number with systemic features during episodes 4 3 9 Fibrosis or bronchiectasis 20 3 4 Median (range) duration of follow up (y) 17 9 (1-31-5) 7 (1-18) 12 (1-29) Thorax: first published as 10.1136/thx.44.11.919 on 1 November 1989. Downloaded from Pulmonary eosinophilia with and without allergic bronchopulmonary aspergillosis 921 Table 3 Clinical and investigativefeatures ofpatients with pulmonary eosinophilia with and without allergic bronchopulmonary aspergillosis (ABPA) ABPA Non-ABPA (n = 33) (n = 32) p Male: female 19:14 8: 24 <001 Atopic 28 17 < 0-02 Asthmatic 32 26 < 0-05 Median (range) age of onset of asthma (y) 7-5 (1-61) 30 5 (2-69) <0 01 Median (range) age of onset of pulmonary eosinophilia (y) 38 (14-78) 40 (13-67) NS Number developing pulmonary eosinophilia before asthma 2 4 NS Maximum blood eosinophil count during episodes x 106/1 (group mean (SD)) 2290 (3584) 3526 (3045) < 0 05 Mean blood eosinophil count during episodes x 1O6/1 (group mean (Sb)) 1406 (1287) 2858 (2919) <001 Number with systemic features during episodes 4 12 < 0 05 Median (range) duration of follow up (y) 17 9 (1-31 5) 10-1 (1-29) <0 05 (median 17i0 v 10 1 years; p < 005). There was no malaise, fever, rashes, and
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