Introduction to Aspergillosis for Non-Specialist Clinicians
Aspergillosis describes a group of lung diseases caused by Aspergillus species—most commonly A. fumigatus. While exposure to spores is universal, disease mainly affects people with asthma, cystic fibrosis, COPD, previous tuberculosis, sarcoidosis, structural lung disease, or immunosuppression. Conditions range from allergic (e.g., ABPA) to chronic (CPA, Aspergillus bronchitis) to invasive disease (IA). Early recognition may reduce diagnostic delays, inappropriate repeated treatment and avoidable morbidity.
At a glance
- Think Aspergillus in difficult-to-control asthma, unexplained bronchiectasis, or cavitary/fibrosing lung disease.
- Tailor investigations to the suspected syndrome: allergic disease (total IgE, A. fumigatus-specific IgE), chronic cavitary disease (CT and Aspergillus IgG), or suspected invasive infection (urgent specialist-directed diagnostics).
- Use local Respiratory/ID pathways and consult current NAC referral criteria for complex cases; do not delay urgent care for suspected invasive disease.
- NAC provides remote Advice & Guidance, virtual MDT, therapeutic drug monitoring (TDM) and resistance testing.
- Check azole interactions at initiation and when co-medications change.
- Upskill rapidly via RCGP eLearning and MIMS Learning.
Clinical spectrum of aspergillosis
| Type | Typical host | Key features | Initial investigations |
|---|---|---|---|
| Allergic Bronchopulmonary Aspergillosis (ABPA) | Asthma / CF | Worsening wheeze, mucus plugs, fleeting infiltrates, high Total IgE, positive Aspergillus-specific IgE/IgG | A. fumigatus-specific IgE and total IgE; eosinophils and Aspergillus IgG as supportive tests; CT when indicated. Interpret against current ISHAM criteria. |
| Severe Asthma with Fungal Sensitisation (SAFS) | Severe/difficult asthma | Fungal sensitisation, poor control without ABPA criteria | Demonstrate fungal sensitisation (specific IgE or skin-prick testing); assess whether ABPA criteria are met. |
| Chronic Pulmonary Aspergillosis (CPA) | COPD, post-TB, sarcoidosis, post-COVID fibrosis, bullous disease | Cavities ± fungal ball, cough, haemoptysis, weight loss, fatigue | Chest CT, Aspergillus IgG and respiratory microbiology where available; correlate with symptoms and radiological progression over at least 3 months. |
| Aspergillus Bronchitis | Bronchiectasis / structural lung disease | Chronic purulent sputum, recurrent infection, positive Aspergillus culture | Repeated sputum fungal cultures or PCR where available, alongside assessment for alternative causes; interpretation requires clinical context. |
| Invasive Aspergillosis (IA) | Immunocompromised, transplant, haematology, ICU | Fever, pleuritic pain, nodules on CT, rapid course | Urgent hospital/specialist assessment; CT and targeted mycology (e.g. respiratory sampling, galactomannan) according to risk and presentation. Do not delay treatment when strongly suspected. |
Diagnostic note: A positive Aspergillus test alone does not establish disease. ABPA, CPA, airway colonisation/bronchitis and invasive aspergillosis have different diagnostic criteria. Interpret serology and microbiology with clinical features, imaging, immune status and specialist advice. A normal chest X-ray does not reliably exclude CPA or invasive disease when suspicion remains high.
National Aspergillosis Centre (NAC)
The National Aspergillosis Centre (NAC) at Wythenshawe Hospital, Manchester University NHS Foundation Trust is the UK’s tertiary referral service for chronic and allergic aspergillosis, commissioned by NHS England as a Highly Specialised Service.
- Complex diagnosis and case review (ABPA, SAFS, CPA, Aspergillus bronchitis)
- Therapeutic drug monitoring (TDM) for itraconazole, voriconazole, posaconazole; resistance testing
- Remote Advice & Guidance (NHS e-RS) and virtual MDT for complex/uncertain cases
- Education, research and training via the Manchester NIHR BRC
Referral & professional info:
NAC – Referrals
Antifungal–drug interactions: why they matter
Systemic triazole antifungals (itraconazole, voriconazole, posaconazole and isavuconazole) have clinically important interactions, but their enzyme effects and interaction profiles differ. Some combinations can increase exposure to co-prescribed medicines (including selected statins, anticoagulants and corticosteroids), causing toxicity or steroid-related adrenal suppression. Enzyme-inducing medicines may reduce azole exposure, while reduced gastric acidity can impair absorption of some itraconazole formulations. Check the specific agent, formulation and full medication list before prescribing and whenever treatment changes. Use a current interaction resource and seek pharmacy or specialist advice for complex combinations.
Quick tools:
University of Manchester Antifungal Interaction Checker ·
BNF Online
Antifungal treatment and monitoring
Oral triazole antifungals, including itraconazole, voriconazole, posaconazole and isavuconazole, are used in the management of different forms of aspergillosis. The choice of treatment depends on the diagnosis, clinical circumstances, potential drug interactions and tolerability.
Therapeutic drug monitoring (TDM) is an important part of treatment with itraconazole and voriconazole. Posaconazole levels may also be monitored, particularly when there are concerns about absorption, treatment response or drug exposure. Routine TDM is not generally required for every patient receiving isavuconazole, although it may be appropriate in selected circumstances.
All systemic triazoles require assessment for clinically important drug interactions and adverse effects. Liver function monitoring and other safety checks should follow the relevant prescribing guidance and the patient’s clinical circumstances.
Patients receiving prolonged antifungal treatment should have their response, tolerability and treatment plan reviewed regularly by their clinical team.
GP & clinician training
- RCGP eLearning: Fungal lung disease & aspergillosis — recognition, testing, referral pathways for primary care:
elearning.rcgp.org.uk - MIMS Learning: Managing aspergillosis & fungal sensitisation in primary care — practical IgE/IgG interpretation and prescribing tips:
mimslearning.co.uk - BTS webinars — case-based updates on CPA, ABPA and antifungal stewardship.
Patient support & education (NAC CARES)
Clinical services are complemented by psychosocial support, education and patient involvement activities intended to support understanding, treatment engagement and wellbeing.
- NAC CARES (Community, Awareness, Research, Education, Support): weekly online support meetings (social, wellbeing, education), patient-friendly materials on airway clearance, nutrition, mental health, medicines safety; PPIE activities; management of aspergillosis.org.
- Partner organisations: The Aspergillosis Trust; moderated patient communities (Telegram/Facebook).
Signpost newly diagnosed patients here: Patient Support at NAC.
Advice & Guidance and remote MDT pathways
Primary care (GPs)
- Investigate according to presentation: for possible ABPA in asthma or bronchiectasis, consider A. fumigatus-specific IgE and total IgE; for suspected CPA with persistent cavities or other suggestive imaging, request Aspergillus IgG and discuss CT with respiratory services. Suspected invasive aspergillosis requires urgent hospital assessment.
- Refer to local Respiratory/ID for further assessment; include imaging, microbiology, steroid/azole history.
Secondary care (Respiratory/ID)
- Use NHS e-RS Advice & Guidance to obtain rapid input from NAC on complex/refractory cases.
- Submit case summaries and imaging for remote NAC MDT discussion; shared-care follow-up is common.
Referral & contact: NAC – Referrals.
Evidence & key publications (CPA)
- Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Thorax. 2015;70(3):270–277.
doi:10.1136/thoraxjnl-2014-206291 - Kosmidis C, Denning DW. Pulmonary aspergillosis in chronic respiratory disease—State of the Art Review. Eur Respir J. 2015;45(1):45–59.
doi:10.1183/09031936.00157514 - Kosmidis C, et al. The burden of fungal infections in the UK. J Infect. 2017;74(S1):S27–S35.
doi:10.1016/S0163-4453(17)30132-8
Guidelines & resources
- British Thoracic Society (BTS) Clinical Statement on Aspergillus-related chronic pulmonary disease, 2025 — UK clinical guidance:
https://www.brit-thoracic.org.uk - NICE Guidance — antifungals, ABPA, severe asthma, biologics:
nice.org.uk - ISHAM Working Group (2024) — ABPA diagnostic criteria update:
isham.org - UK government public health guidance — fungal disease overview:
gov.uk - University of Manchester Antifungal Interaction Checker:
antifungalinteractions.org BNF online - Aspergillosis.org — NAC, professional and patient resources:
aspergillosis.org
Summary
Aspergillosis sits at the intersection of allergy, infection and chronic lung disease. For GPs and non-specialist clinicians, the essentials are awareness, syndrome-specific investigation (allergy testing for suspected ABPA; imaging and Aspergillus IgG for suspected CPA; urgent specialist assessment for invasive disease), timely local referral, and vigilance for antifungal interactions. The National Aspergillosis Centre supports UK clinicians with remote A&G, virtual MDTs, TDM and resistance testing, and patient-support services designed to improve information, engagement and quality of life.
Did this page help you?
Tell us in one minute