⚠️ Warning Signs for Possible Aspergillosis in Primary Care

We often state that a GP does not need to know all the details of what aspergillosis is, they just need to know what the warning signs might be so that they know when they should refer the patient to their local hospital specialist. What are those warning signs?

🟠 1. Asthma Not Responding to Guidelines-Based Treatment

• Poor control despite high-dose inhaled steroids or long-acting bronchodilators

• Frequent oral steroid bursts (>2 in a year)

• Persistent cough or breathlessness between attacks

• Thick or brown mucus plugs coughed up

🟢 Ask: “Are you still having symptoms even though you’re taking all your preventers?”

🟠 2. Recurrent Chest Infections

• Multiple antibiotic courses (especially in bronchiectasis or COPD patients)

• Sputum samples that repeatedly show Aspergillus or colonising fungi

• Chest x-rays showing cavities, nodules, or persistent infiltrates

🟢 Ask: “Have you had several chest infections this year that needed antibiotics or steroids?”

🟠 3. Unexplained Fatigue, Weight Loss, or Night Sweats

• Especially if imaging shows lung abnormalities or patient is immunocompromised

• May indicate CPA, not just asthma

🟢 Ask: “Have you lost weight without trying, or felt unusually tired for weeks?”

🟠 4. Pre-existing Lung Conditions with New or Worsening Symptoms

• Especially in patients with:

  • Bronchiectasis

  • COPD/emphysema

  • Old TB

  • Sarcoidosis

• These conditions increase risk of CPA or colonisation becoming invasive

🟠 5. High Total IgE or Eosinophils

• Total IgE > 1000 IU/mL with asthma + mucus plugs = strong ABPA clue

• Blood eosinophils persistently >0.5 (especially off steroids)

• Aspergillus-specific IgE or IgG positive

🟢 Flag: “Could this patient have allergic fungal disease or ABPA?”

🟠 6. Radiology That Doesn’t Match the Diagnosis

• If the patient is being treated as asthma or pneumonia but:

  • HRCT shows bronchiectasis with mucus plugging

  • X-rays don’t improve despite treatment

  • Old TB scar now shows a cavity

🟢 Flag: “Does this imaging suggest something more than asthma or infection?”

🧭 What Should GPs and Nurses Do Next?

✅ Request:

• Blood tests: Total IgE, eosinophils, Aspergillus-specific IgE/IgG

• Sputum for fungal culture if available

• CXR or HRCT if not done recently

✅ Refer:

• Respiratory specialist or Advice & Guidance

• National Aspergillosis Centre (NAC) in Manchester is a national specialist (tertiary) NHS centre, so does not accept referrals directly from GP’s, instead GP’s should refer to their local respiratory specialist team at a hospital nearby. NHS referral structure

📋 Clinical Triggers for Flagging Aspergillosis