ABPA (allergic bronchopulmonary aspergillosis): symptoms, diagnosis and treatment

Aspergillosis is a condition caused by breathing in the spores of aspergillus mould, which is found in soil, compost, rotting leaves, plants, dust, bedding, damp buildings and air conditioning systems, according to the NHS. Most people who breathe in the spores do not get ill because their immune system deals with them, and Asthma + Lung UK describes it as a rare condition affecting less than 1 in 2,000 people.

There are several types. The NHS lists allergic bronchopulmonary aspergillosis (ABPA), an allergy to aspergillus mould; chronic pulmonary aspergillosis (CPA), a long-term lung infection; aspergilloma, a ball of mould in the lungs often linked to CPA; and invasive pulmonary aspergillosis (IPA), a life-threatening infection in people with a weakened immune system. ABPA is different from the infection types because it is an allergic reaction. Asthma + Lung UK adds severe asthma with fungal sensitisation (SAFS) and aspergillus bronchitis to the list.

Asthma + Lung UK says ABPA mostly affects people with asthma and can lead to symptoms getting worse or an asthma attack, and that it can also affect people with cystic fibrosis. The NHS says you are usually only at risk of aspergillosis if you have a lung condition such as asthma, cystic fibrosis or COPD, a weakened immune system, past tuberculosis, or severe flu or COVID-19 needing artificial ventilation.

It is not caught from another person. The NHS says aspergillosis is rare in healthy people.

The NHS lists symptoms of aspergillosis as shortness of breath, a cough that may bring up blood or lumps of mucus, wheezing, a high temperature, losing weight without trying and feeling tired. Asthma + Lung UK adds chest pain or discomfort and notes that if you already have a lung condition you may notice your lung condition symptoms get worse.

In someone with asthma, an ABPA problem may therefore look like asthma that has become harder to control, with more wheeze and breathlessness, more mucus and repeated flare-ups, despite usual inhalers.

The NHS says aspergillosis can be difficult to diagnose and may take time. A GP will check that symptoms are not caused by something else, like a chest infection, and if they are not sure what is causing the symptoms may refer you to a specialist for tests such as X-rays and scans, blood tests or tests on a sample of mucus, allergy tests and a bronchoscopy.

Asthma + Lung UK explains that allergy tests can show whether you are allergic or sensitive to aspergillus mould, but that this does not always mean you have aspergillosis, so you may need a specialist for more tests, which can sometimes take time because symptoms resemble other lung conditions and chest infections.

The NHS says treatment depends on the type and usually aims to help control symptoms, and for ABPA lists steroid tablets and antifungal tablets. Asthma + Lung UK says that if you have ABPA your doctor may prescribe steroid tablets with or without antifungal medicines, that steroids treat inflammation in the airways, and that some people who take steroids for a long time may need a steroid card.

It explains that antifungal medicines are the main treatment for all types of aspergillosis, need to be taken for weeks, months or sometimes longer, and should be taken as the full course to help prevent resistance. They can interact with other medicines, including steroids, so tell all your doctors what you take.

Some people with ABPA or SAFS may be offered a biologic, a specialist treatment given by injection in hospital, which can work well for some people, improving symptoms and avoiding the need for long-term steroids. Airway clearance techniques taught by a respiratory physiotherapist help to clear mucus, reduce coughing and lower the risk of chest infection. As with all medicines, steroids and antifungals can have side effects, so check the patient leaflet and talk to your team if you are worried.

It is almost impossible to avoid aspergillus completely, but the NHS suggests avoiding compost heaps and piles of dead leaves, opening windows several times a day to air rooms especially when cooking or showering, wearing a face mask in dusty places or when gardening, considering a dehumidifier and an air purifier with a HEPA filter, and keeping the house heated between 18 and 21C in cold weather. It advises not drying laundry in bedrooms or living areas and not opening windows when there is construction work or digging outside.

Asthma + Lung UK adds that gardening and time outside may be best avoided when fungal spores are worse, such as autumn, and recommends quitting smoking, staying as active as you can, getting the annual flu vaccine and COVID-19 boosters if eligible, and looking after your mental health.

The NHS advises seeing a GP if you have had a cough for more than 3 weeks, if you have a lung condition that is getting worse or harder to control with your usual treatment, or if you have a weakened immune system and symptoms of aspergillosis. It advises asking for an urgent GP appointment or contacting NHS 111 if you cough up blood.

Severe breathlessness, chest pain, coughing up a lot of blood, or being unable to speak in full sentences needs 999 or A&E. Keep your asthma action plan up to date and make sure your specialist team knows about any change.