Substance Info: (and synonyms)
Aspergillus fumigatus (Mould)

Background Info:

The species A. fumigatus was already well described and illustrated in the 1850's by Fresenius, who worked with lung material from birds dying of aspergillosis. It is a thermotolerant fungus with world-wide distribution. Due to a rather wide temperature range for good growth it is not limited to habitats with permanently high temperatures, even though there it is obviously very frequently reported. It is found in soils, leaf, and plant litter, decaying vegetables and roots, bird droppings, tobacco, stored sweet potatoes. In comparison with other aeroallergens, the concentration of spores in the air is low though there may be high localised counts.

Fungi related to allergies are commonly found in dwelling environments. The predominant fungi Cladosporium, Penicillium, Aspergillus, Alternaria, Wallemia and Rhodotorula live mainly in indoor air, house dust (HD), futons, clothes and contaminated building materials. See Aspergillus niger


Adverse Reactions:


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Allergic bronchopulmonary aspergillosis (ABPA) is an immunological pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus, manifesting with poorly controlled asthma, recurrent pulmonary infiltrates and bronchiectasis. There are estimated to be in excess of four million patients affected world-wide. The importance of recognizing ABPA relates to the improvement of patient symptoms, and delay in development or prevention of bronchiectasis, one manifestation of permanent lung damage in ABPA. Environmental factors may not be the only pathogenetic factors because not all asthmatics develop ABPA despite being exposed to the same environment. Allergic bronchopulmonary aspergillosis is probably a polygenic disorder, which does not remit completely once expressed, although long-term remissions do occur. In a genetically predisposed individual, inhaled conidia of A. fumigatus germinate into hyphae with release of antigens that activate the innate and adaptive immune responses (Th2 CD4(+) T cell responses) of the lung. The International Society for Human and Animal Mycology (ISHAM) has constituted a working group on ABPA complicating asthma (, which convened an international conference to summarize the current state of knowledge, and formulate consensus-based guidelines for diagnosis and therapy. New diagnosis and staging criteria for ABPA are proposed. Although a small number of randomized controlled trials have been conducted, long-term management remains poorly studied. Primary therapy consists of oral corticosteroids to control exacerbations, itraconazole as a steroid-sparing agent and optimized asthma therapy. Uncertainties surround the prevention and management of bronchiectasis, chronic pulmonary aspergillosis and aspergilloma as complications, concurrent rhinosinusitis and environmental control. There is need for new oral antifungal agents and immunomodulatory therapy (Agarwal 2013 ref.29180 8)

Agarwal R, Chakrabarti A, Shah A, Gupta D, Meis JF, Guleria R, Moss R, Denning DW. Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria. Clin Exp Allergy 2013 Aug;43(8):850-873

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Allergic sensitization is not associated with recovery of Candida or Aspergillus from the sputum of patients with CF. Aspergillus but not Candida sensitization is associated with greater lung function decline and pulmonary exacerbations (Baxter 2013 ref.29526 4)

Baxter CG, Moore CB, Jones AM, Webb AK, Denning DW. IgE-mediated immune responses and airway detection of Aspergillus and Candida in adult cystic fibrosis. Chest 2013 May;143(5):1351-1357

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This Californian study of 53 children ranging in age from 1 to 6 years who had mild to moderate atopic dermatitis, showed significant positive correlations between objective SCORAD and specific IgE levels for the fungi A fumigatus, Malassezia species, C herbarum, and C albicans. The data further showed that persistent asthma was associated with fungal IgE sensitizations, particularly to C albicans and
C herbarum, in young children with AD. (Ong 2012 ref.27554 7)

Ong PY, Ferdman RM, Church JA. Association of microbial IgE sensitizations with asthma in young children with atopic dermatitis. Ann Allergy Asthma Immunol 2012 Mar;108(3):212-213

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Non occupational chronic hypersensitivity pneumonitis due to Aspergillus fumigatus on leaky walls. (Mitsui 2012 ref.27855 7)

Mitsui C, Taniguchi M, Fukutomi Y, Saito A, Kawakami Y, Mori A, Akiyama K. Non occupational chronic hypersensitivity pneumonitis due to Aspergillus fumigatus on leaky walls. Allergol Int 2012 Jun 25;0(0):

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Epidemiologic studies in the United States and Europe have associated mold sensitivity, particularly to Alternaria alternata and Cladosporium herbarum, with the development, persistence, and severity of asthma. In addition, sensitivity to Aspergillus fumigatus has been associated with severe persistent asthma in adults. Allergic bronchopulmonary aspergillosis (ABPA) is caused by A fumigatus and is characterized by exacerbations of asthma, recurrent transient chest radiographic infiltrates, coughing up thick mucus plugs, peripheral and pulmonary eosinophilia, and increased total serum IgE and fungus-specific IgE levels, especially during exacerbation. The airways appear to be chronically or intermittently colonized by A fumigatus in patients with ABPA. ABPA is the most common form of allergic bronchopulmonary mycosis (ABPM); other fungi, including Candida, Penicillium, and Curvularia species, are implicated. The characteristics of ABPM include severe asthma, eosinophilia, markedly increased total IgE and specific IgE levels, bronchiectasis, and mold colonization of the airways. The term severe asthma associated with fungal sensitization (SAFS) has been coined to illustrate the high rate of fungal sensitivity in patients with persistent severe asthma and improvement with antifungal treatment. The immunopathology of ABPA, ABPM, and SAFS is incompletely understood.

Knutsen AP, Bush RK, Demain JG, Denning DW, Dixit A, Fairs A, Greenberger PA, Kariuki B, Kita H, Kurup VP, Moss RB, Niven RM, Pashley CH, Slavin RG, Vijay HM, Wardlaw AJ. Fungi and allergic lower respiratory tract diseases. J Allergy Clin Immunol 2012 Feb;129(2):280-291

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This study assessed the frequency and pattern of high-resolution computed tomography (HRCT) abnormality and the relationship with Aspergillus fumigatus sensitization in one severe asthma population. Of 133 patients analysed, 111 (83.4%) had an abnormal HRCT with bronchial wall thickening (41.3%), bronchiectasis (35.3%), air trapping (20.3%) and bronchial dilatation (16.5%) occurring most frequently. Radiological evidence of airway disease was associated with more obstructive spirometry. A. fumigatus sensitization was associated with a 2.01 increased hazard ratio of bronchiectasis (95% CI 1.26 to 3.22, P = 0.005), and more obstructive spirometry. Patients with A. fumigatus sensitization had variable clinical and radiological characteristics that frequently did not conform to the conventional diagnostic criteria for ABPA. Therefore sensitization to A. fumigatus is associated with bronchiectasis and greater airflow obstruction, even when diagnostic criteria for ABPA are not met. (Menzies 2011 ref.25711 7)

Menzies D, Holmes L, McCumesky G, Prys-Picard C, Niven R. Aspergillus sensitization is associated with airflow limitation and bronchiectasis in severe asthma. Allergy 2011 Jan 25;

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All patients with asthma and/or rhinosinusitis along with sensitisation to Aspergillus antigens are at an increased risk of developing ABPA and/or AAS. ABPA must be excluded in all patients with AAS and vice versa. Early diagnosis and initiation of appropriate therapy could plausibly alter the course of the disease processes and prevent the possible development of long term sequelae. (Panjabi 2011 ref.28819 5)

Panjabi C, Shah A. Allergic Aspergillus sinusitis and its association with allergic bronchopulmonary aspergillosis. Asia Pac Allergy 2011 Oct;1(3):130-137

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Five patients (three women) (mean age 41 years) with hypersensitivity pneumonitis due to exposure to dry sausage dust. Three patients developed an acute form of disease and two patients a subacute form. Specific IgG to Penicillium frequentans and Aspergillus fumigatus were positive for three patients. Performed on three patients, the specific inhalation challenge was positive for dry sausage dust extract in two cases and Penicillium frequentans in the third. (Morell 2011 ref.27429 0)

Morell F, Cruz MJ, Gomez FP, Rodriguez-Jerez F, Xaubet A, Munoz X. Chacinero's lung - hypersensitivity pneumonitis due to dry sausage dust. Scand J Work Environ Health 2011 Jul;37(4):349-356

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A Danishstudy in order to determine the prevalence, significance, and susceptibility pattern of aspergilli in airway samples was conducted. Routine microbiologic investigation were examined for Aspergillus. A total of 11,368 airway samples were received. Growth of Aspergillus spp. was found in 129 and 151 patients using routine and extended incubation, respectively. Three patients had proven Invasive aspergillosis (IA) (2%), 11 probable (7%), four had allergic bronchopulmonary aspergillosis (ABPA) (3%), but the majority was colonised (88%). Underlying conditions were cystic fibrosis in 82 patients (55%), chronic obstructive pulmonary disease in 19 (13%) and haematological disorder in 11 (7%). Twenty-six patients (18%) were at intensive care unit and 69 (47%) received steroid treatment. Isolates included A. fumigatus, A. lentulus, A. terreus. (Mortensen 2011 ref.26747 5)

Mortensen KL, Johansen HK, Fuursted K, Knudsen JD, Gahrn-Hansen B, Jensen RH, Howard SJ, Arendrup MC. A prospective survey of Aspergillus spp. in respiratory tract samples: prevalence, clinical impact and antifungal susceptibility. Eur J Clin Microbiol Infect Dis 2011 May 4. [Epub ahead of print]

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Severe asthma and fungi: Aspergillus species seem to be the strongest candidates as only with Aspergillus spp. does one encounter two extreme immunologic phenomena, i.e., the Aspergillus-sensitive asthma and allergic bronchopulmonary aspergillosis. (d 2011 ref.26094 7)

Agarwal R, Gupta D. Severe asthma and fungi: current evidence. Med Mycol 2011 Apr;49 Suppl 1:S150-7.

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Aspergillus fumigatus regulates mite allergen-pulsed dendritic cells in the development of asthma. (Fukahori 2010 ref.24837 8)

Fukahori S, Matsuse H, Tsuchida T, Kawano T, Tomari S, Fukushima C, Kohno S. Aspergillus fumigatus regulates mite allergen-pulsed dendritic cells in the development of asthma. Clin Exp Allergy 2010 Apr 19;

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This study attempted to define the relationship between the clinical and laboratory features of Aspergillus fumigatus-associated asthma by studing 79 patients with asthma (89% classed as GINA 4 or 5) classified into 3 groups according to A. fumigatus sensitization: (1) IgE-sensitized (immediate cutaneous reactivity > 3 mm and/or IgE > 0.35 kU/L); (2) IgG-only-sensitized (IgG > 40 mg/L); and (3) nonsensitized. A. fumigatus was cultured from 63% of IgE-sensitized patients with asthma (n = 40), 39% of IgG-only-sensitized patients with asthma (n = 13), 31% of nonsensitized patients with asthma (n = 26) and 7% of healthy control subjects (n = 14). Patients sensitized to A. fumigatus compared with nonsensitized patients with asthma had lower lung function, more bronchiectasis, and more sputum neutrophils. In a multilinear regression model, A. fumigatus-IgE sensitization and sputum neutrophil differential cell count were important predictors of lung function, supported by culture of A. fumigatus and eosinophil differential cell count.

Fairs A, Agbetile J, Hargadon B, Bourne M, Monteiro WR, Brightling CE, Bradding P, Green RH, Mutalithas K, Desai D, Pavord ID, Wardlaw AJ, Pashley CH. IgE sensitization to Aspergillus fumigatus is associated with reduced lung function in asthma. Am J Respir Crit Care Med 2010 Dec 1;182(11):1362-1368

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Allergic fungal sinusitis (AFS) is a noninvasive form of fungal rhinosinusitis with an incidence of between 6 and 9% of all rhinosinusitis requiring surgery. Regional variation in incidence has been reported, with the southern and southwestern US particularly endemic. Patients with AFS commonly present with chronic rhinosinusitis with nasal polyps, inhalant atopy, elevated total serum immunoglobulin E (IgE), and sinus-obstructing inspissates of a characteristic extramucosal 'peanut buttery' visco-elastic eosinophil-rich material called 'allergic mucin' that contains sparse numbers of fungal hyphae. Sinus CT is always abnormal, showing findings of chronic rhinosinusitis that often include central areas of increased contrast ('hyperattenuation') within abnormal paranasal sinuses that represent the presence of fungal-containing allergic mucin. AFS has been found to be analogous in several ways to allergic bronchopulmonary aspergillosis (ABPA). Both are chronic inflammatory respiratory tract disorders that are driven by hypersensitivity responses to the presence of small numbers of extramucosal fungi found growing within airway-impacting allergic mucin. AFS allergic mucin typically cultures positive for either dematiaceous fungi such as Bipolaris spicifera or Curvularia lunata, or Aspergillus species such as A. fumigatus, A. flavus or A. niger. As with ABPA, patients have type I immediate hypersensitivity to the etiologic mold in AFS. Further, both AFS and ABPA have been found to have association with specific class II major histocompatibility alleles. Proper diagnosis of AFS and differentiation from the other forms of both noninvasive and invasive fungal rhinosinusitis requires strict adherence to published diagnostic criteria.

Schubert MS. Allergic fungal sinusitis: pathophysiology, diagnosis and management. Med Mycol 2009;47 Suppl 1:S324-30.

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Factors expressed on the surface of mature A. fumigatus hyphae that are controlled by StuA and MedA induce mast cell degranulation in the absence of IgE. (Urb 2009 ref.26660 2)

Urb M, Pouliot P, Gravelat FN, Olivier M, Sheppard DC. Aspergillus fumigatus induces immunoglobulin E-independent mast cell degranulation. J Infect Dis 2009 Aug 1;200(3):464-72.

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Thirty-four adult atopic subjects were randomized into mold-sensitive groups based on skin test reactivity by skin percutaneous testing (SPT) and/or intradermal (ID) testing to a mixed mold (MM) extract preparation (Aspergillus fumigatus, Aspergillus niger, Fusarium oxysporum, Alternaria tenuis, Epicoccum nigrum, Hormodendrum cladosporioides, Pullularia sp., Penicillium notatum, Mucor racemosus, and Trichophyton rubrum). Based on challenge results and scoring model, mold-sensitive subjects compared with nonmold-sensitive subjects experienced cumulatively higher symptom scores after oral challenge to an MM extract preparation. Future studies are warranted to confirm whether ingestion of aeroallergenic molds in food may be another contributor to symptoms in mold-sensitive individuals. (Luccioli 2009 ref.24507 7)

Luccioli S, Malka-Rais J, Nsouli TM, Bellanti JA. Clinical reactivity to ingestion challenge with mixed mold extract may be enhanced in subjects sensitized to molds. Allergy Asthma Proc 2009 Jul;30(4):433-442

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This study was performed to delineate the prevalence of, and evaluate possible risk factors for, adverse reactions to SPT in a prospective study of 5,908 patients aged Generalized allergic reactions
1. Boy, 5 m, eczema. Tested with 4 allergens, positive for cow’s milk and egg. After 10 min developed generalized urticaria, severe pruritus, swelling of the arm where the tests were performed, and excessive crying.
2. Boy, 6 m, eczema. Test with cow’s milk. After 10 min, generalized erythema, severe pruritus, itchy, red conjunctivae, vomiting.
3. Girl, 6 m, eczema. SPT with 5 allergens. Positive to egg, milk, wheat, rye, dog. Generalized urticaria, severe pruritus and reddening of eczema over the whole body.
4. Girl, 8 m, occasional urticaria when exposed to a casein hydrolysate formula on the skin, drop test negative. SPT with two allergens, both positive (Nutramigen and Profylac). After 10-15 min urticaria and pruritus.
5. Boy, 5.5 y, eczema, allergy to cow’s milk and egg. SPT to four allergens, positive to egg white and dog. After 10 min, sore throat, hoarseness, becomes pale, starts to cough and goes into cold sweat.
6. Boy, 10.5 y, with asthma and urticaria occasionally. SPT with 4 allergens, positive to almond and peanut. Complains of nasal congestion after 10 min.
7. Boy, 11 y, eczema, rhinitis, asthma. SPT with 9 allergens, positive tests to 7 (dog, cat, horse, birch, timothy, Cladosporium and Aspergillus). Nasal congestion and red, itchy and watery eyes.
(Norrman 2009 ref.23010 7)

Norrman G, Falth-Magnusson K. Adverse reactions to skin prick testing in children - Prevalence and possible risk factors. Pediatr Allergy Immunol 2009 Feb 4;

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Aspergillus spp produce a wide range of saprophytic and invasive syndromes in the lungs, including allergic bronchopulmonary aspergillosis (ABPA), aspergilloma and invasive pulmonary aspergillosis (IPA). ABPA results from hypersensitivity to the fungus, and mainly affects patients with asthma or cystic fibrosis (CF). IPA is predominantly seen in patients with haematological malignancies, chronic granulomatous disease or immunosuppressive treatment. With the use of aggressive therapies for end-stage CF, such as heart-lung transplantation, the potential for a patient to convert from colonization or ABPA to IPA has increased. (Hatziagorou 2009 ref.26751 2)

Hatziagorou E, Walsh TJ, Tsanakas JN, Roilides E. Aspergillus and the paediatric lung. Paediatr Respir Rev 2009 Dec;10(4):178-85.

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This study aimed to determine the frequency of familial occurrence in 164 patients with ABPA diagnosed over a period of 22 years in one unit. 164 patients with ABPA were reviewed for the occurrence of familial ABPA. A familial occurrence was documented in 4.9% of the 164 patients with ABPA. (Shah 2008 ref.22546 0)

Shah A, Kala J, Sahay S, Panjabi C. Frequency of familial occurrence in 164 patients with allergic bronchopulmonary aspergillosis. Ann Allergy Asthma Immunol 2008 Oct;101(4):363-9

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Hypersensitivity pneumonitis and asthma attacks caused by environmental fungi in a 75-year-old man. The diagnosis was established by inhalation challenge with Bjerkandera adusta and Aspergillus fumigatus. (Katayama 2008 ref.22650 0)

Katayama N, Fujimura M, Yasui M, Ogawa H, Nakao S. Hypersensitivity pneumonitis and bronchial asthma attacks caused by environmental fungi. Allergol Int 2008 Sep;57(3):277-280

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Allergic bronchopulmonary aspergillosis with hilar adenopathy in a 42-month-old boy. (Shah 2007 ref.20665 5)

Shah A, Kala J, Sahay S. Allergic bronchopulmonary aspergillosis with hilar adenopathy in a 42-month-old boy. Pediatr Pulmonol 2007 Aug;42(8):747-748

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A 58-year-old woman had a productive cough but not from bronchial asthma. A chest radiograph revealed infiltrative shadows. Aspergillus fumigatus was detected in a sputum culture. After the treatment, infiltrative shadows on her chest radiograph disappeared. On October 2005, her peripheral blood showed eosinophilla, a high serum level of total immunoglobulin E (IgE), and a chest radiograph revealed new infiltrative shadows in both lung fields. Aspergillus niger was detected in a bronchial lavage fluid. A diagnosis of allergic bronchopulmonary aspergillosis (ABPA). It is critical to consider the both aspects of allergy and infection in the treatment for ABPA. (Isobe 2007 ref.26679 3)

Isobe Z, Suga T, Hamaguchi S, Hara K, Aoki N, Aoki F, Aoyagi K, Ueno M, Maeno T, Case of allergic bronchopulmonary aspergillosis successfully treated with itraconazole. [Japanese] Arerugi 2007 Nov;56(11):1390-6.

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Allergic bronchopulmonary aspergillosis, allergic Aspergillus sinusitis, and aspergilloma can occur simultaneously in the same patient. (Shah 2006 ref.14296 0)

Shah A, Panjabi C. Contemporaneous occurrence of allergic bronchopulmonary aspergillosis, allergic Aspergillus sinusitis, and aspergilloma. Ann Allergy Asthma Immunol 2006 Jun;96(6):874-878

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All consecutive patients with asthma presenting to a north Indian chest clinic over a period of 2 years were screened with an Aspergillus skin test. Five hundred sixty-four patients were screened using an Aspergillus skin test; 223 patients (39.5%) were found to be positive, and ABPA was diagnosed in 126 patients (27.2%). There were 34 patients (27%) with ABPA-S, 42 patients with ABPA-CB, and 50 patients with ABPA-CB-ORF. (Agarwal 2006 ref.15735 7)

Agarwal R, Gupta D, Aggarwal AN, Behera D, Jindal SK. Allergic bronchopulmonary aspergillosis: lessons from 126 patients attending a chest clinic in north India. Chest 2006 Aug;130(2):442-448

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Esparto is one the most frequent causes of hypersensitivity pneumonitis in Spain. In this study, both healthy and exposed plasterers have higher levels of specific IgG to Aspergillus fumigatus, Saccharopolyspora rectivirgula and Thermoactynomices vulgaris than the healthy controls. The patients had higher levels of IgG than exposed healthy plasterers only to Thermoactynomices vulgaris. Precipitins were detected in only two patients. There were no occupational factors influencing on the sensitisation process. (Gamboa 2005 ref.11701 5)

Gamboa PM, Urbaneja F, Olaizola I, Boyra JA, Gonzalez G, Antepara I, Urrutia I, Jauregui I, Sanz ML. Specific IgG to Thermoactynomices vulgaris, Micropolyspora faeni and Aspergillus fumigatus in building workers exposed to esparto grass (plasterers) and in patients with esparto-induced hypersensitivity pneumonitis. J Investig Allergol Clin Immunol 2005;15(1):17-21.

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Mold-induced hypersensitivity pneumonitis. (Greenberger 2004 ref.11182 5)

Greenberger PA. Mold-induced hypersensitivity pneumonitis. Allergy Asthma Proc 2004;25(4):219-23

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Allergic bronchopulmonary aspergillosis (ABPA) occurs as a complication of bronchial asthma or cystic fibrosis (CF). The diagnostic criteria speak to an exaggerated type I hypersensitivity response to the ubiquitous organism Aspergillus fumigatus. (Slavin 2004 ref.11264 5)

Slavin RG, Hutcheson PS, Chauhan B, Bellone CJ. An overview of allergic bronchopulmonary aspergillosis with some new insights. Allergy Asthma Proc 2004;25(6):395-9

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Allergic bronchopulmonary aspergillosis (ABPA) is an immunologically complex allergic disorder induced by the fungal pathogen Aspergillus fumigatus. ABPA is clinically characterized by episodic bronchial obstruction; positive immediate skin reactivity; elevated total immunoglobulin E (IgE), specific IgG, and IgE antibodies; peripheral and pulmonary eosinophilia; central bronchiectasis; and expectoration of brown plugs. (Madan 2004 ref.11796 5)

Madan T, Priyadarsiny P, Vaid M, Kamal N, Shah A, Haq W, Katti SB, Sarma PU. Use of a synthetic peptide epitope of Asp f 1, a major allergen or antigen of Aspergillus fumigatus, for improved immunodiagnosis of allergic bronchopulmonary aspergillosis. Clin Diagn Lab Immunol 2004;11(3):552-8

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In an Italian study, skin prick tests were applied to a cohort of 4962 respiratory subjects, aged 3-80 years. Fungal extracts from Alternaria, Aspergillus, Candida, Cladosporium, Penicillium, Saccharomyces, and Trichophyton were used, along with extracts from pollens, mites, and animal dander. Nineteen percent of the allergic population reacted to at least one fungal extract by means of the skin test. Alternaria and Candida accounted for the largest number of positive tests, and along with Trichophyton they were the main sensitizers in the subset of patients with an isolated sensitization. (Mari 2003 ref.10913 4)

Mari A, Schneider P, Wally V, Breitenbach M, Simon-Nobbe B. Sensitization to fungi: epidemiology, comparative skin tests, and IgE reactivity of fungal extracts. Clin Exp Allergy 2003;33(10):1429-38

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These findings suggests that A. fumigatus is an important causative agent in allergic fungal sinusitis in the southeast United States. (McCann 2002 ref.6663 9)

McCann WA, Cromie M, Chandler F, Ford J, Dolen WK. Sensitization to recombinant Aspergillus fumigatus allergens in allergic fungal sinusitis. Ann Allergy Asthma Immunol 2002;89(2):203-8

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In this study, the allergenic significance of thirteen species of Aspergillus and their allergenic and antigenic relationship was studied. Of the 3025 ID tests performed with the 13 species of Aspergillus on 289 patients suffering with allergic respiratory diseases, 627 (20.7%) were positive (1+ to 4+), 386 (12.8%) being significantly positive (2+ to 4+). Of the 64 patients eliciting a positive cutaneous response to at least one species, 42(65.6%) were positive to 5 or less number of species while others showed a broad spectrum of positive skin reactivity to different Aspergillus extracts. In RAST inhibition assays using pooled sera of patients sensitive to A. tamarii dose related inhibition was produced by homologous as well as 5 of the 12 heterologous species. Similarly, in A. terreus RAST inhibition was observed with homologous and A. tamarii extracts only. Our results suggested the presence of both species specific as well as shared allergenic components among different Aspergillus species. In experiments of A. tamarii and A. terreus extracts, multiple precipitin bands were observed with the homologous extracts. However, only 1-2 bands were produced by 6 heterologous Aspergillus species in each system. Collectively, these results gave evidence that there is heterogeneity of immune response in the patients with allergic respiratory diseases to different species of Aspergillus and also in rabbits immunized with Aspergillus extracts. (Aggarwal 2000 ref.23147 5)

Aggarwal S, Chhabra SK, Saxena RK, Agarwal MK. Heterogeneity of immune responses to various Aspergillus species in patients with allergic respiratory diseases. Indian J Chest Dis Allied Sci 2000 Oct-Dec;42(4):249-58.

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In 553 asthmatics in Kuwait, sensitisation to common aeroallergens as measured by serum specific IgE was: pollens (87.1%), house dust (76.1%), and molds (30.3%). The three most prevalent sensitizing pollens were from Chenopodium (S. kali) (70.7%), Bermuda grass (62.9%), and Prosopis (62.7%), all of which are horticultural plants imported for the purpose of "greening" the desert.
Frequency of sensitization to individual allergens among confirmed extrinsic asthmatics:
Allergens All patients (n=482)
Chenopodium weed 70.7
Bermuda grass 62.9
Prosopis tree 62.7
Cockroach 58.5
Cajeput tree 53.5
D. pteronyssinus 46.5
D. microceras 44.8
Eucalyptus tree 42.9
Date palm 39.6
D. farinae 38.6
Cat dander 30.9
Aspergillus 22.2
Alternaria 14.7
Cladosporium 14.1
(Ezeamuzie 2000 ref.4940 5)

Ezeamuzie CI, Thomson MS, Al-Ali S, Dowaisan A, Khan M, Hijazi Z. Asthma in the desert: spectrum of the sensitizing aeroallergens. Allergy 2000;55(2):157-62

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Four workers in medical research laboratories, located in a basement level of a University facility equipped with a humidified air conditioning system, complained of cough and/or asthma and/or rhinitis during their normal working activities. Aspergillus fumigatus and Penicillium notatum were found in some laboratories. Eight laboratory workers (including the 4 symptomatic subjects) out of 26 investigated were found to be atopic. Specific IgE sensitisation to Aspergillus fumigatus was found in the 8 atopic and in the 6 non-atopic workers, while Penicililum notatum was found in 7 atopic and 4 non-atopic subjects. The presence of aspergillosis or allergic bronchial aspergillosis in the sensitised subjects was excluded. Our results suggest that evaluation of immune parameters, along with monitoring of the working environment, may reduce the risk of sensitisation and/or allergic symptoms in atopic laboratory workers. (Boscolo 1999 ref.11471 0)

Boscolo P, Piccolomini R, Benvenuti F, Catamo G, Di Gioacchino M. Sensitisation to Aspergillus fumigatus and Penicillium notatum in laboratory workers. Int J Immunopathol Pharmacol 1999;12(1):43-8

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Allergic fungal sinusitis is a comparatively new disease entity in paranasal sinus mycoses. Of 28 consecutive cases of allergic nasal polyposis during a 2-year period, 11 patients had allergic fungal sinusitis and the diagnosis was based on the presence of type I hypersensitivity, eosinophilic mucus without tissue invasion of fungi on histopathology and detection of septate hyphae on direct microscopy. On culture, Aspergillus flavus was isolated from nine patients and A. fumigatus and A. niger from one patient each. (Chhabra 1996 ref.26723 3)

Chhabra A, Handa KK, Chakrabarti A, Mann SB, Panda N. Allergic fungal sinusitis: clinicopathological characteristics. Mycoses 1996 Nov-Dec;39(11-12):437-41.

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This study evaluated 540 Sri-Lankan patients with severe bronchial asthma and 96 patients with mild or moderate asthma. Of these 134 were subjected to detailed examinations in the form of a skin test, serological test, sputum examination and peripheral blood eosinophil count. Eight patients (1.2% of the total and 6% of selected patients) had evidence of ABPA. A further 50 patients (8% of total and 37% of selected patients) had evidence of allergy to the fungus as depicted by positive skin test reactivity. The latter patients could be either early ABPA or potential candidates for the development of ABPA later. Skin test sensitivity to both Aspergillus fumigatus and A niger were demonstrated in Sri-Lankan asthmatics. Skin test sensitivity could be considered a screening test for the diagnosis of ABPA. (Attapattu 1991 ref.26701 9)

Attapattu MC. Allergic bronchopulmonary aspergillosis among asthmatics. Ceylon Med J 1991 Jun;36(2):45-51.

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In a Japanes study, using skin prick tests and radioallergosorbent tests (RAST) on 94 asthmatic patients (mean age 12.0), A. restrictus, A. fumigatus, A. alternata and house dust elicited positive reactions in 8 (8.5%), 8 (8.5%), 15 (16.0%) and 69 (73.4%) patients, respectively. RAST showed positive reactions in 27 (28.7%) subjects for A. restrictus, 22 (23.4%) for A. fumigatus, 35 (37.2%) for A. alternata, and 75 (79.8%) for house dust.(Sakmoto 1990 ref.6926 4)

Sakamoto T, Ito K, Yamada M, Iguchi H, Ueda M, Matsuda Y, Torii S. Allergenicity of the osmophilic fungus Aspergillus restrictus evaluated by skin prick test and radioallergosorbent test. [Japanese] Arerugi 1990;39(11):1492-8

[ 36 / 47 ]

Farmer's lung in infants and small children. A boy and a girl, 10 weeks and 3 years of age, respectively, were admitted with low temperature, dry cough, fatigue and weight loss. In both patients pulmonary X-rays showed diffuse, bilateral, micronodular infiltrations, and sparse signs of fibrosis. Serum IgG and blood eosinophils were abnormally high. However, after a few days at home, they were readmitted with the same symptoms. Family histories revealed that the children lived on farms with huge grain magazines and dryers, where moist grain and straw were stored. Massive amounts of mould spores were cultured from the residential areas, and, in addition, the male patient had an elevated titer to Micropolyspora faeni and the female patient, elevated titers to Thermoactinomyces vulgaris, Micropolyspora faeni, Aspergillus fumigatus and Alternaria alternans. The patients and their families moved from the farms and, for approximately a year, have been without lung symptoms. (Thorshauge 1989 ref.14256 7)

Thorshauge H, Fallesen I, Ostergaard PA. Farmer's lung in infants and small children. Allergy 1989 Feb;44(2):152-5.

[ 37 / 47 ]

In a study in Sao Paulo, Brazil, evaluating sensitisation in 201 patients with asthma and/or allergic rhinitis to 42 airborne fungi using skin specific IgE tests, 15 were shown to be sensitised to Alternaria, 15 to Aspergillus, 23 to Aureobasidium, 37 to Candida, 15 to Chaetomium, 19 to Epicoccum, 17 to Mucor, 20 to Phoma, 19 to Trichoderma, and 14 to Rhizopus. . (Mohovic 1988 ref.11297 5)

Mohovic J, Gambale W, Croce J. Cutaneous positivity in patients with respiratory allergies to 42 allergenic extracts of airborne fungi isolated in Sao Paulo, Brazil. Allergol Immunopathol (Madr) 1988;16(6):397-402

[ 38 / 47 ]

Several allergenic components have been identified. A. fumigatus and niger appear to be allergenically distinct from the versicolor, nodulus, glaucus groups. (Burge 1985 ref.1226 8)

Burge HA Fungus Allergens. Clin Rev Allergy 1985;3:319-329

[ 39 / 47 ]

The possible role of marijuana (MJ) in inducing sensitization to Aspergillus organisms was studied in 28 MJ smokers by evaluating their clinical status and immune responses to microorganisms isolated from MJ. The spectrum of illnesses included one patient with systemic aspergillosis and seven patients with a history of bronchospasm after the smoking of MJ. Twenty-one smokers were asymptomatic. Fungi were identified in 13 of 14 MJ samples and included Aspergillus fumigatus, A. flavus, A. niger, Mucor, Penicillium, and thermophilic actinomycetes. Precipitins to Aspergillus antigens were found in 13 of 23 smokers and in one of 10 controls, while significant blastogenesis to Aspergillus was demonstrated in only three of 23 MJ smokers. When samples were smoked into an Andersen air sampler, A. fumigatus passed easily through contaminated MJ cigarettes. Thus the use of MJ assumes the risks of both fungal exposure and infection, as well as the possible induction of a variety of immunologic lung disorders. (Kagen 1983 ref.26696 0)

Kagen SL, Kurup VP, Sohnle PG, Fink JN. Marijuana smoking and fungal sensitization. J Allergy Clin Immunol 1983 Apr;71(4):389-93.

[ 40 / 47 ]

Acute exogenous allergic alveolitis with the typical symptoms of unproductive cough, dyspnoea on exertion, fever, loss of weight, headache and limb pains was observed in a 24-year-old bank employee. The differential diagnosis of allergic alveolitis was confirmed by the demonstration of precipitating antibodies in serum against Pullularia pullulans, Trichoderma viride, Cephalosporium acremonium and Aspergillus fumigatus, moulds with an ubiquitous occurrence. The source of exposition leading to the disease were pot plant earth and containers in the patient's flat. Moulds could be isolated from these substrates. (Velcovsky 1981 ref.25545 5)

Velcovsky HG, Graubner M. Allergic alveolitis following inhalation of mould spores from pot plant earth (author's transl). [German] Dtsch Med Wochenschr 1981 Jan 23;106(4):115-20.

[ 41 / 47 ]

Ouchterlony precipitin results with antisera from workers afflicted with either farmer's or mushroom worker's lung were positive for Bacillus licheniformis, Micropolyspora faeni, Thermoactinomyces vulgaris, Aspergillus fumigatus, Humicola grisea var. thermoidea, spent compost, and phase II compost. (Kleyn 1981 ref.15262 7)

Kleyn JG, Johnson WM, Wetzler TF. Microbial aerosols and actinomycetes in etiological considerations of mushroom workers' lungs. Appl Environ Microbiol 1981 Jun;41(6):1454-60.

[ 42 / 47 ]

A patient in whom a clinical picture resembling allergic bronchopulmonary aspergillosis was found to be caused by hypersensitivity to the fungus Stemphylium lanuginosum. Bronchopulmonary reactions to antigens other than Aspergillus may be more frequent than is currently believed. Cross-reacting antigens between Stemphylium and Aspergillus may be responsible for this. (Benatar 1980 ref.25860 7)

Benatar SR, Allan B, Hewitson RP, Don PA. Allergic bronchopulmonary stemphyliosis. Thorax 1980 Jul;35(7):515-8.

[ 43 / 47 ]

290 asthmatic patients with positive skin tests for mould allergens were analyzed retrospectively. Tests with Alternaria alternata, Aureobasidium pullulans, Penicillium notatum, Fusarium culmorum, Aspergilus fumigatus and Cladosporium herbarum showed the highest correlation with clinical allergy. (Kersten 1980 ref.11485 7)

Kersten W, Hoek GT. Mould allergy (author's transl). [German] Wien Med Wochenschr 1980;130(8):275-82

[ 44 / 47 ]

Other diseases such as extrinsic allergic alveolitis (hypersensitivity pneumonitis), Farmer's Lung, invasive aspergillosis, and aspergilloma are also linked to this mould. (Gravesen 1979 ref.1224 8)

Gravesen S. Fungi as a cause of allergic disease. Allergy 1979;34:135-154

[ 45 / 47 ]

A study of 46 cases of allergic bronchopulmonary aspergillosis. Episodic airways obstruction and dual skin reaction to aspergillin were present in all the cases. Furthermore, there were pulmonary infiltrations in 91.1%, blood eosinophilia in 80.4%, precipitins in 91.3%, and sputum cultures repeatedly positive for A. fumigatus in 82.6% of the patients. It was observed that the multiplicity of precipitin bands corresponded to the higher recovery of A. fumigatus in culture. A. flavus and A. niger were recovered from 58.7 and 80.4% cases of allergic bronchopulmonary aspergillosis respectively but dual skin reactions to these species occurred only in 47.6 and 26.2% and precipitins in 21.7 and 4.3% of cases, respectively. The findings are compatible with the poor allergenic and antigenic properties attributed to these two species in comparison with A. fumigatus. It is suggested that allergic bronchopulmonary aspergillosis may not be too uncommon in India and it deserves greater attention in the differential diagnosis of chest diseases. (Khan 1976 ref.26689 3)

Khan ZU, Sandhu RS, Randhawa HS, Menon MP, Dusaj IS. Allergic bronchopulmonary aspergillosis: a study of 46 cases with special reference to laboratory aspects. Scand J Respir Dis 1976;57(2):73-87.

[ 46 / 47 ]

Serological studies in 15 patients with bird fanciers disease are reported. Serum proteins showed elevation of IgG in almost every case. High IgE was observed in three patients with isolated asthmatic reactions. In four patients alpha1-antitrypsin was transiently diminished. Precipitins against avian sera and avian droppings were found in all patients, but also in some exposed and nonexposed controls. Cross-reactions to avian antigens from different species were observed quite regularly in patients but not in controls. One case is presented suggesting that these cross-reactions may be of clinical importance. Precipitins against other inhaled antigens such as Aspergillus fumigatus, cereals or Micropolyspora faeni were observed significantly more frequently in patients than in controls. These precipitins showed no cross-reactions with those against avian antigens. (Müller 1976 ref.22179 2)

Müller U, de Haller R, Grob PJ. Serological investigations in 15 cases of bird fanciers disease. Int Arch Allergy Appl Immunol 1976;50(3):341-58.

[ 47 / 47 ]

Inhalation of conidia and mycelium of A. fumigatus can lead to several diseases, the severity of which depends on the host's immune responses, of which allergic asthma, allergic bronchopulmonary aspergillosis involve specific IgE antibodies. Specific IgE antibody against A. fumigatus was found in 81.8% of cases with confirmed clinical hypersensitivity. Phadebas RAST confirmed allergy specialists' diagnosis in 78.8% of the cases. (Virchow 1975 ref.1219 7)

Virchow C, Roth A, Debelic M, Möller E. Radio-allergo-sorbent-test (RAST) bei Schimmelpilzsporensensibilisierung. Praxder Pneum 1975;29:555-567

Non-Immune reactions

[ 1 ]

A Danishstudy in order to determine the prevalence, significance, and susceptibility pattern of aspergilli in airway samples was conducted. Routine microbiologic investigation were examined for Aspergillus. A total of 11,368 airway samples were received. Growth of Aspergillus spp. was found in 129 and 151 patients using routine and extended incubation, respectively. Three patients had proven Invasive aspergillosis (IA) (2%), 11 probable (7%), four had allergic bronchopulmonary aspergillosis (ABPA) (3%), but the majority was colonised (88%). Underlying conditions were cystic fibrosis in 82 patients (55%), chronic obstructive pulmonary disease in 19 (13%) and haematological disorder in 11 (7%). Twenty-six patients (18%) were at intensive care unit and 69 (47%) received steroid treatment. Isolates included A. fumigatus, A. lentulus, A. terreus. (Mortensen 2011 ref.26747 5)

Mortensen KL, Johansen HK, Fuursted K, Knudsen JD, Gahrn-Hansen B, Jensen RH, Howard SJ, Arendrup MC. A prospective survey of Aspergillus spp. in respiratory tract samples: prevalence, clinical impact and antifungal susceptibility. Eur J Clin Microbiol Infect Dis 2011 May 4. [Epub ahead of print]

[ 2 ]

Severe pneumonia caused by combined infection with Pneumocystis jiroveci, parainfluenza virus type 3, cytomegalovirus, and Aspergillus fumigatus in a patient with Stevens-Johnson syndrome/toxic epidermal necrolysis. (Lee 2010 ref.26050 8)

Lee T, Bae YJ, Park SK, Park HJ, Kim SH, Cho YS, Moon HB, Lee SO, Kim TB. Severe pneumonia caused by combined infection with Pneumocystis jiroveci, parainfluenza virus type 3, cytomegalovirus, and Aspergillus fumigatus in a patient with Stevens-Johnson syndrome/toxic epidermal necrolysis. Acta Derm Venereol 2010 Nov;90(6):625-629

[ 3 ]

A defective mucociliary clearance facilitates colonization with bacteria and fungal spores in cystic fibrosis patients. Yeasts and molds are cultured from the cystic fibrosis respiratory tract and often their clinical relevance is unknown. Candida spp. are the most commonly isolated yeasts, whereas Aspergillus spp., Scedosporium apiospermum, as well as Exophiala dermatitidis in some countries, are the most frequent molds recovered from respiratory specimens. Persistent Aspergillus fumigatus infection is associated with an increased risk of pulmonary exacerbations requiring hospitalization. The prevalence of non-Aspergillus molds may be underestimated due to overgrowth of Pseudomonas and Aspergillus spp. on routine media. (Müller 2010 ref.26750 5)

Müller FM, Seidler M. Characteristics of pathogenic fungi and antifungal therapy in cystic fibrosis. Expert Rev Anti Infect Ther 2010 Aug;8(8):957-64.

[ 4 ]

Aspergillus species contribute to approximately 25 % of all cases of fungal endocarditis. Ten sera in total from five patients were extracted for Aspergillus DNA and nested PCR with Aspergillus species primers was carried out. The PCR was positive in three patients. Culture of valvular tissue confirmed the growth of Aspergillus fumigatus in one patient and Aspergillus niger in two patients. (Badiee 2009 ref.26667 5)

Badiee P, Alborzi A, Shakiba E, Ziyaeyan M, Pourabbas B. Molecular diagnosis of Aspergillus endocarditis after cardiac surgery. J Med Microbiol 2009 Feb;58(Pt 2):192-5.

[ 5 ]

Invasive aspergillosis is rare in immunocompetent people but contributes to significant morbidity and mortality in immunosuppressed patients. The majority (approximately 80%) of invasive Aspergillus infections is caused by Aspergillus fumigatus. The second most frequent (approximately 15-20%) pathogenic species is Aspergillus flavus and to a lesser extent, Aspergillus niger and Aspergillus terreus. Aspergillus flavus has emerged as a predominant pathogen in patients with fungal sinusitis and fungal keratitis in several institutions worldwide. To date, there has not been any publication exclusively reviewing the topic of A. flavus in the literature. This article reviews the microbiology, toxigenicity and epidemiology of A. flavus as well as describes the clinical characteristics, diagnosis and management of infections caused by this organism. (Krishnan 2009 ref.26665 7)

Krishnan S, Manavathu EK, Chandrasekar PH. Aspergillus flavus: an emerging non-fumigatus Aspergillus species of significance. Mycoses 2009 May;52(3):206-22.

[ 6 ]

Aspergillus fumigatus, Scedosporium apiospermum and Aspergillus terreus for filamentous fungi and Candida albicans for yeasts are the main fungal species associated with cystic fibrosis. Although less common, several fungal species including Aspergillus flavus and Aspergillus nidulans may be isolated transiently from CF respiratory secretions, while others such as Exophiala dermatitidis and Scedosporium prolificans may chronically colonize the airways. Moreover, some of them like Penicillium emers onii and Acrophialophora fusispora are encountered in humans almost exclusively in the context of CF. (Pihet 2009 ref.25556 0)

Pihet M, Carrere J, Cimon B, Chabasse D, Delhaes L, Symoens F, Bouchara JP. Occurrence and relevance of filamentous fungi in respiratory secretions of patients with cystic fibrosis--a review. Med Mycol 2009 Jun;47(4):387-97.

[ 7 ]

Disseminated intravascular coagulation (DIC) is a rarely described finding in invasive pulmonary aspergillosis. (Lai 2007 ref.25189 5)

Lai CC, Liaw SJ, Lee LN, Hsiao CH, Yu CJ, Hsueh PR. Invasive pulmonary aspergillosis: high incidence of disseminated intravascular coagulation in fatal cases. J Microbiol Immunol Infect 2007 Apr;40(2):141-7.

[ 8 ]

The clinical features of 59 chronic pulmonary aspergillosis cases (aspergilloma, chronic necrotizing pulmonary aspergillosis) was evaluated. X-ray findings were a fungus ball type in 47% of cases and thickened wall of a cavity type in 32%. Positive sputum culture found was A. fumigatus 78%, A. niger 13% and A. flavus 2%. Positive rates of serologic tests showed precipitating antibody 81% and antigen 11%; 39% of beta-D glucan exceeded the reference value. A pathogenic factor, elastase was isolated from Aspergillus spp., and we also found the elastase inhibitor from this series. Five of 12 strains of A. fumigatus, and one of 2 strains of A. flavus expressed elastase inhibitory activity when we screened for the culture supernatant of various Aspergillus spp. of a clinical isolate. Elastase inhibitory activity from A. niger was very weak. Culture supernatants from 5 strains of A. fumigatus and one strain of A. flavus were stable for a fever, and human leucocyte elastase was inhibited, but these did not inhibit porcine pancreas elastase. (Ogawa 2006 ref.26685 5)

Ogawa K, Okumura Y, Nikai T, Tarumi O, Nakagawa T, Saitou Y. Clinical analysis of chronic pulmonary aspergillosis and discovery of an elastase inhibitor. [Japanese] Nihon Ishinkin Gakkai Zasshi 2006;47(3):171-8.

[ 9 ]

Abundant respirable ergot alkaloids from the common airborne fungus Aspergillus fumigatus. (Panaccione 2005 ref.23882 5) (However the study did not evaluate whether this could have an adverse effect in humans.)

Panaccione DG, Coyle CM. Abundant respirable ergot alkaloids from the common airborne fungus Aspergillus fumigatus. Appl Environ Microbiol 2005 Jun;71(6):3106-11

[ 10 ]

This Turkish study was to determine the prevalence of causative non-dermatophytic filamentous fungi in onychomycosis. Samples of nail scrapings from 1,146 patients with prediagnosis of onychomycosis sent to the Mycology Laboratory prospectively studied. As agents of onychomycosis molds were detected in 33 (9%), dermatophytes in 175 (48%), yeasts in 150 (41%), and mixed (two different fungi) in 8 (2%) patients. The agents of mold onychomycosis, in order of frequency, were Aspergillus niger (7), Acremonium spp. (6), Fusarium spp. (6), Ulocladium spp. (4), sterile mycelia (2), Alternaria sp. (1), Aspergillus flavus (1), Aspergillus fumigatus (1), Aspergillus terreus (1), Cladosporium sp. (1), Paecilomyces spp. (1), Scopulariopsis sp. (1) and Trichoderma sp. (1). (Hilmioglu-Polat 2005 ref.25759 3)

Hilmioglu-Polat S, Metin DY, Inci R, Dereli T, Kilinç I, Tümbay E. Non-dermatophytic molds as agents of onychomycosis in Izmir, Turkey - a prospective study. Mycopathologia 2005 Sep;160(2):125-8.

[ 11 ]

"Toxic mold syndrome" is a controversial diagnosis associated with exposure to mold-contaminated environments. Molds are known to induce asthma and allergic rhinitis through IgE-mediated mechanisms, to cause hypersensitivity pneumonitis through other immune mechanisms, and to cause life-threatening primary and secondary infections in immunocompromised patients. Mold metabolites may be irritants and may be involved in "sick building syndrome." Patients with environmental mold exposure have presented with atypical constitutional and systemic symptoms, associating those symptoms with the contaminated environment. This study's objective was to characterize the clinical features and possible etiology of symptoms in patients with chief complaints related to mold exposure. The distribution of fungal species in patients with positive SPT or ICT reactions attributed 5 patients to Chaetomium globosum. (No details though). (Edmondson 2005 ref.11405 8)

Species Number of patients
Alternaria alternata 5
Acremonium strictum 4
Apiospora montagnei 2
Aspergillus fumigatus 6
Aspergillus niger 2
Aureobasidium pullulans 5
Botrytis cinerea 2
Candida albicans 3
Candida tropicalis 3
Cladosporium cladosporioides 3
Cladosporium fulvum 5
Chaetomium globosum 5
Chrysosporium pruinosum 5
Colletotrichum atramentarium 2
Drechslera sorokiniana 2
Drechslera spicifera 5
Epicoccum nigrum 8
Fusarium oxysporum 6
Geotrichum candidum 2
Gliocladium fimbriatum 4
Hypocrea rufa 3
Microsporum audouinii 3
Microsporum canis 7
Monilia sitophila 5
Mucor racemosus 6
Nigrospora oryzae 7
Paecilomyces variotii 2
Penicillium chrysogenum 9
Phoma destructiva 5
Rhizopus nigricans 5
Rhodotorula rubra 9
Saccharomyces cerevisiae 6
Scopulariopsis brevicaulis 4
Stachybotrys chartarum 5
Stemphylium herbarum 10
Streptomyces griseus* 7
Syncephalastrum species 5
Tetracoccosporium species 3
Trichothecium roseum 2
Trichophyton rubrum 3
(Edmondson 2005 ref.11405 8)

Edmondson DA, Nordness ME, Zacharisen MC, Kurup VP, Fink JN. Allergy and "toxic mold syndrome". Ann Allergy Asthma Immunol 2005;94(2):234-9.

[ 12 ]

Osteomyelitis due to Aspergillus spp. in patients with chronic granulomatous disease: comparison of Aspergillus nidulans and Aspergillus fumigatus. (Dotis 2004 ref.25193 2)

Dotis J, Roilides E. Osteomyelitis due to Aspergillus spp. in patients with chronic granulomatous disease: comparison of Aspergillus nidulans and Aspergillus fumigatus. Int J Infect Dis 2004 Mar;8(2):103-10.

[ 13 ]

Systemic Aspergillus presenting with visual symptoms. (Telander 2004 ref.25192 5)

Telander DG, Pambuccian SE, Olsen TW. Systemic Aspergillus presenting with visual symptoms. Retina 2004 Feb;24(1):166-8.

[ 14 ]

Hepatic abscess caused by Aspergillus fumigatus infection is rare: a case of Aspergillus fumigatus infection in a 66-year-old man with aplastic anemia who presented with intermittent high fever. (Lee 2003 ref.25195 7)

Lee TY, Yang SS, Chen GH, Hwang WL, Lin YH, Hwang JI. Hepatic abscess caused by Aspergillus fumigatus infection following splenectomy and immunosuppressive therapy. J Formos Med Assoc 2003 Jul;102(7):501-5.

[ 15 ]

Endogenous Aspergillus endophthalmitis (AE) is a rare complication of invasive aspergillosis (IA) in transplant patients. (Schelenz 2003 ref.25194 3)

Schelenz S, Goldsmith DJ. Aspergillus endophthalmitis: an unusual complication of disseminated infection in renal transplant patients. J Infect 2003 Nov;47(4):336-43.

[ 16 ]

In this Finnish study, an association between sinusitis and elevated mould-specific IgG-levels for Aspergillus fumigatus, Aspergillus versicolor, Aureobasidium pullulans, Chaetomium globosum, Cladosporium cladosporioides, Phialophora bubakii, Rhodotorula glutinis, Sporobolomyces salmonicolor, Stachybotrys atra, and Tritirachium roseum was found in the study group. (Patovirta 2003 ref.24288 7)

Patovirta RL, Reiman M, Husman T, Haverinen U, Toivola M, Nevalainen A. Mould specific IgG antibodies connected with sinusitis in teachers of mould damaged school: a two-year follow-up study. Int J Occup Med Environ Health 2003;16(3):221-30.

[ 17 ]

Invasive subglottal aspergillosis in a patient with severe aplastic anemia: a case report. (Nagasawa 2002 ref.25197 0)

Nagasawa M, Itoh S, Tomizawa D, Kajiwara M, Sugimoto T, Kumagai J. Invasive subglottal aspergillosis in a patient with severe aplastic anemia: a case report. J Infect 2002 Apr;44(3):198-201.

[ 18 ]

Incidence of mycoses in bronchopulmonary disorders: 274 samples were collected. Main fungus was Candida albicans from sputum (45.5 percent), from bronchial secretions (14.6 percent). Rest were Aspergillus, Alternaria and Helminthosporium. All the pleural aspirates were negative for fungus. (Kumar 1992 ref.25881 0)

Kumar S, Kumar R, Saini S, Sabherwal U, Arora DR. Incidence of mycoses in bronchopulmonary disorders. Indian J Pathol Microbiol 1992 Jul;35(3):237-40.

[ 19 ]

The extracts of A. fumigates are aflatoxic. (Legator 1983 ref.1227 8)

Legator MS, Kline G, et al. Aflotoxin B1 in mould extracts used for desensitization. [Letter] Lancet 1983;Oct15

[ 20 ]

Mycological examinations of morning sputum of patients with chronic bronchitis and bronchial asthma was performed. A fumigatus and A. niger was isolated from patients chronic bronchitis in frequency of 4.5% and 0.8% respectively. These 2 fungi has also been isolated from patients with bronchial asthma in frequency of 24.5% (A. fumigatus) and 2.4% (A. niger). (Colak 1982 ref.26693 7)

Colak H, Yulug N. Aspergilli and chronic lung diseases. [Turkish] Mikrobiyol Bul 1982 Jan;16(1):15-9.

[ 21 ]

A patient in whom a clinical picture resembling allergic bronchopulmonary aspergillosis was found to be caused by hypersensitivity to the fungus Stemphylium lanuginosum. Bronchopulmonary reactions to antigens other than Aspergillus may be more frequent than is currently believed. Cross-reacting antigens between Stemphylium and Aspergillus may be responsible for this. (Benatar 1980 ref.25860 7)

Benatar SR, Allan B, Hewitson RP, Don PA. Allergic bronchopulmonary stemphyliosis. Thorax 1980 Jul;35(7):515-8.

[ 22 ]

Three weeks after a massive inhalation of mold present on infected oats, a farmer's wife had extrinsic allergic alveolitis. Aspergillus fumigatus was cultured from the moldy oats and from deep bronchial washings obtained at fiberoptic bronchoscopy. (Yocum 1976 ref.7594 4)

Yocum MW, Saltzman AR, Strong DM, Donaldson JC, Ward GW Jr, Walsh FM, Cobb OM Jr, Elliott RC. Extrinsic allergic alveolitis after Aspergillus fumigatus inhalation. Evidence of a type IV immunologic pathogenesis. Am J Med 1976;61(6):939-45

[ 23 ]

Nondermatophyte onychomycosis account for 2% to 12% of all nail fungal infections and can be caused by a wide range of fungi, mainly Scopulariopsis brevicaulis, Aspergillus versicolor, A. flavus, A. niger, A. fumigatus, Fusarium solani, F. oxysporum and Scytalidium spp. Among the predisposing factors are footwear, hyperhidrosis, local trauma, peripheral circulatory disease, and immunosuppression. These nondermatophyte fungi lack the keratinolytic capacity of dermatophytes, but they still can infect alone or in combination with the latter. Because most are considered laboratory cont

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