Q:

49 year old severe asthmatic was seen in consult. Lab evaluation shows elevated IgE of 2530. ABPA panel through IBT shows negative IgE to aspergillus but aspergillus fumigatus mix gel diffusion is positive and IgG is 46 mcg/ml (reference<46). Skin prick test is positive for multiple environmental allergens. SPT reaction to aspergillus is questionable. I cannot pinpoint any other etiology for her elevated IgE than the environmental allergies. My question is, is this still ABPA?
Thank you.

A:

Thank you for your recent inquiry.

As you know, Dr. Paul Greenberger is an internationally known expert regarding the diagnosis and management of patients with allergic bronchopulmonary aspergillosis. I am therefore asking Dr. Greenberger for his thoughts in regards to your case. As soon as I hear from him, I will forward his response to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.


Below is the response we received from Dr. Paul Greenberger. Thank you again for your inquiry, and we hope this response is helpful.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. Paul Greenberger:
No. To meet criteria for ABPA, one needs to demonstrate anti-Aspergillus IgE antibodies.  When the SPT is negative, we perform an intradermal test with an extract of Aspergillus fumigatus. If negative, as long as the extract is reactive, for practical purposes you have excluded ABPA. A mix of Aspergillus species used for SPT or in vitro diagnostics may have minimal epitopes of Aspergillus fumigatus resulting in a true negative test, even if the patient has anti-Apergillus fumigatus IgE antibodies.
 
If a high resolution CT examination of the chest is performed in a patient with ABPA, there will be proximal bronchiectasis and perhaps mucus plugging or infiltrates. If present in your patient, that suggests ABPA or ABPmycosis. Some patients with persistent severe asthma who have positive SPT to Aspergillus fumigatus, have demonstrable proximal bronchiectasis but of less severity and distribution than patients with APBA.
 
The total IgE concentration may be elevated because of associated eczema, which when in association with asthma, often causes a much higher total IgE concentration than in people with asthma without eczema. Some additional causes of an elevated total IgE concentration in a patient with persistent severe asthma include ABPmycosis (is any skin test for molds positive?), Churg Strauss Syndrome (any palpable purpura or paresthesias or neuropathy?), recurrent serious lung infections or skin abscesses (Hyper IgE syndrome that may mimic or co-exist with ABPA). Parasitism is another cause for completeness.

Paul Greenberger, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology