Weekly Aspergillosis Research Update: New Diagnostics, CAPA Evidence, and Why Azole Tolerance Matters
Last reviewed: 23 June 2026
Author: National Aspergillosis Centre Team
Audience: People living with aspergillosis, carers, healthcare professionals, and interested readers.
In one sentence: This week's aspergillosis research highlights a possible new bronchoscopic approach to aspergilloma management, growing use of PCR diagnostics, a major review of COVID-19-associated pulmonary aspergillosis, and new discoveries explaining how Aspergillus fumigatus may survive antifungal treatment.
Research Highlight of the Week
Why azole tolerance is more complex than resistance
The most important scientific theme this week is the growing recognition that Aspergillus fumigatus can sometimes survive antifungal treatment without possessing classic resistance mutations. Three separate studies suggest that iron availability, cellular stress responses, epigenetic regulation and long non-coding RNA may all influence how the fungus responds to azole drugs. These findings do not change treatment today, but they could shape future approaches to antifungal resistance monitoring and antifungal drug development.
Who Should Read This Update?
This update may be particularly relevant for:
- People living with chronic pulmonary aspergillosis (CPA)
- People with aspergilloma or a history of haemoptysis (coughing up blood)
- Patients receiving antifungal treatment such as itraconazole, voriconazole, posaconazole or isavuconazole
- Healthcare professionals interested in aspergillosis diagnostics and antifungal resistance
- Anyone following developments in fungal disease research
Key Points
- A study explored bronchoscopic removal of aspergilloma in selected patients with post-tuberculosis chronic cavitary pulmonary aspergillosis.
- Real-time polymerase chain reaction (PCR) testing may provide additional support when diagnosing invasive aspergillosis.
- A major review confirms that COVID-19-associated pulmonary aspergillosis (CAPA) remains a serious complication of severe COVID-19.
- New research suggests that antifungal treatment response is influenced by much more than simple resistance mutations.
- None of these findings should lead patients to change treatment without specialist medical advice.
Contents
- Overview
- A possible new approach for aspergilloma
- PCR testing and invasive aspergillosis
- COVID-19-associated pulmonary aspergillosis
- Why azole tolerance is more complex than resistance
- Also noted this week
- What this means for patients
- When to speak to your clinical team
- References
Overview
Research into aspergillosis continues to advance on several fronts. This week's papers range from practical clinical studies investigating new ways to manage aspergilloma, through to laboratory research exploring how Aspergillus fumigatus survives antifungal treatment.
While none of these studies are likely to change patient care immediately, they highlight important trends in the field. Researchers are working to improve diagnosis, develop new treatment approaches, and better understand why some infections persist despite treatment.
The strongest overall message this week is that aspergillosis research is moving beyond simple categories such as “susceptible” or “resistant”. Aspergillus fumigatus can adapt to stress, tolerate antifungal pressure, and sometimes survive long enough to acquire more stable resistance.
Most of the studies featured this week improve our understanding of aspergillosis rather than changing treatment directly. Nevertheless, several findings point towards future improvements in diagnosis, patient monitoring and antifungal therapy.
A Possible New Approach for Aspergilloma
One of the most clinically interesting papers this week investigated bronchoscopic removal of aspergilloma in patients with post-tuberculosis chronic pulmonary aspergillosis (CPA).
An aspergilloma, sometimes called a fungal ball, develops when Aspergillus grows within an existing cavity in the lung. These cavities can develop after conditions such as tuberculosis, sarcoidosis, or previous severe lung infections.
Post-tuberculosis chronic cavitary pulmonary aspergillosis refers to CPA developing in lung cavities left behind after previous tuberculosis.
Traditionally, treatment options include antifungal medication, surgery in carefully selected patients, and procedures such as bronchial artery embolisation to control significant bleeding.
This study explored whether bronchoscopy could be used to remove fungal material directly from affected cavities.
Why many patients will find this interesting: Antifungal treatment can help control chronic pulmonary aspergillosis, but it does not usually remove an established fungal ball. Surgery can sometimes be curative, but many patients are not suitable surgical candidates because of reduced lung function or other medical conditions. A successful bronchoscopic approach could eventually provide an additional option for selected patients.
Why is this important?
Many patients with chronic pulmonary aspergillosis are not suitable candidates for surgery because of reduced lung function or other health problems. A bronchoscopic approach could potentially offer a less invasive alternative in selected cases.
However, several important questions remain unanswered:
- Which patients benefit most?
- How often does the aspergilloma return?
- What is the risk of bleeding?
- Is antifungal treatment still required afterwards?
- How durable are the results over longer follow-up?
At present, this should be viewed as a promising specialist-centre approach rather than a new standard of care.
Evidence strength: Clinical interventional study.
Practice-changing now? No. Potentially important, but not yet routine management.
Bottom line: Bronchoscopic removal of aspergilloma is an interesting specialist approach that may eventually help some patients who are unsuitable for surgery, but it is not yet standard treatment.
Read more:
Investigating the efficacy and safety of bronchoscopic removal of aspergilloma in PTB-CCPA
PCR Testing May Help Diagnose Invasive Aspergillosis
Another paper examined the role of real-time polymerase chain reaction (PCR) testing in diagnosing invasive aspergillosis.
PCR detects fungal genetic material and can potentially identify infection more quickly than conventional culture methods.
Why is this important?
Diagnosing invasive aspergillosis remains challenging. No single test is perfect, and clinicians often need to combine information from:
- CT scans and other imaging
- Bronchoscopy findings
- Fungal culture
- Microscopy
- Galactomannan testing
- Clinical risk factors
PCR has been studied for many years, but its performance varies depending on the patient group, sample type, laboratory method and whether the patient has already received antifungal treatment.
This study supports the growing role of molecular diagnostics but does not suggest that PCR should replace existing tests. Instead, it reinforces the idea that combining several diagnostic approaches usually provides the most reliable diagnosis.
A key caution is that PCR detects fungal DNA. It does not always prove invasive disease. This is especially important in people with structurally abnormal lungs, where colonisation can complicate interpretation.
Evidence strength: Diagnostic utility study.
Practice-changing now? No. PCR may be a useful additional test but should always be interpreted alongside the wider clinical picture.
Bottom line: PCR is becoming an increasingly useful diagnostic tool, but it works best when combined with scans, biomarkers, culture results and clinical assessment.
Read more:
Utility of Real-Time PCR in the Diagnosis of Invasive Aspergillosis
Five Years of Evidence on COVID-19-Associated Pulmonary Aspergillosis
Researchers also published a major umbrella review examining evidence from 2020 to 2025 on COVID-19-associated pulmonary aspergillosis (CAPA).
CAPA emerged during the COVID-19 pandemic as an important complication affecting some patients with severe COVID-19, particularly those requiring intensive care.
What did the review find?
The review confirms that CAPA remains associated with:
- Severe illness
- Intensive care admission
- Mechanical ventilation
- High mortality
However, estimating exactly how common CAPA is remains difficult.
Different studies used different definitions, diagnostic methods and screening approaches, making direct comparison challenging. Bronchoscopy was also limited in many settings early in the pandemic, which affected how cases were detected and classified.
Studies have also differed because of:
- Different diagnostic criteria
- Changes in COVID-19 treatment over time
- Vaccination status
- Use of corticosteroids and immunomodulators
- Different intensive care unit screening practices
The review is valuable because it brings together several years of evidence, but it is unlikely to change current management directly.
Evidence strength: Umbrella review and meta-meta-analysis.
Practice-changing now? No. It reinforces awareness rather than introducing a new treatment approach.
Bottom line: CAPA remains a serious complication of severe COVID-19, but this review largely confirms what clinicians already suspected rather than changing current practice.
Read more:
Incidence, Mortality and Risk Factors in COVID-19-Associated Pulmonary Aspergillosis (CAPA)
Why Azole Tolerance Is More Complex Than Resistance
The most scientifically important theme this week comes from three studies investigating how Aspergillus fumigatus survives exposure to azole antifungal drugs.
For many years, discussions about antifungal treatment failure have focused heavily on resistance mutations, particularly changes involving the CYP51A gene. These mutations can make the fungus less susceptible to antifungal drugs such as itraconazole, voriconazole, posaconazole and isavuconazole.
However, these new studies suggest the situation may be considerably more complicated.
Researchers found that fungal survival may also be influenced by:
- Iron availability
- Mitochondrial function
- Epigenetic regulation
- Long non-coding RNA molecules
Why this matters for patients: Laboratory testing may sometimes suggest that an Aspergillus isolate is susceptible to treatment, yet the infection can still prove difficult to control. Researchers increasingly believe that fungal tolerance and stress-response mechanisms may help explain some of these situations. Understanding these processes could eventually lead to better resistance monitoring and more effective treatments.
Resistance vs Tolerance: What's the Difference?
Resistance and tolerance are related but different concepts.
Resistance usually refers to genetic changes that allow the fungus to continue growing despite exposure to an antifungal drug.
Tolerance refers to the ability of some fungal cells to survive drug exposure without necessarily having permanent resistance mutations.
This distinction matters because tolerance may allow the fungus to persist long enough to eventually acquire more stable resistance.
In simple terms, researchers are increasingly asking whether some cases of treatment failure occur because the fungus first becomes tolerant and only later becomes resistant.
The emerging model:
Azole exposure → Temporary tolerance → Fungal survival → Opportunity for resistance mutations → Stable resistance
Iron Starvation and Azole Tolerance
One study found that iron starvation may increase azole tolerance in Aspergillus fumigatus through effects on mitochondrial function.
Iron is essential for both humans and fungi. During infection, the immune system attempts to limit fungal access to iron as part of a defence strategy known as nutritional immunity.
The study suggests that when iron becomes scarce, the fungus may alter its metabolism in ways that help it survive antifungal stress.
This does not mean that iron supplements or dietary changes would affect antifungal treatment. The work is exploring complex biological processes occurring within infected tissues.
Instead, the study provides another clue about how the fungus adapts to hostile conditions inside the body.
Evidence strength: Mechanistic laboratory research.
Practice-changing now? No.
Epigenetics and the Development of Resistance
Perhaps the most influential paper this week examined an epigenetic mechanism that appears to promote azole tolerance and facilitate the later development of antifungal resistance.
Epigenetics refers to changes in gene activity that occur without altering the underlying DNA sequence itself.
In recent years, researchers have increasingly recognised that fungal adaptation is not driven solely by permanent genetic mutations. Instead, fungi can alter gene activity in response to environmental stress.
This study supports a model in which antifungal exposure may trigger a temporary tolerant state. That tolerant state may then allow some fungal cells to survive long enough to acquire permanent resistance mutations.
Importantly, this does not replace the existing understanding of CYP51A-mediated resistance. Instead, it expands it.
Rather than viewing resistance as a single event, researchers are increasingly seeing it as a process that may develop over time.
Evidence strength: Strong mechanistic evidence.
Practice-changing now? No, but potentially important for future resistance monitoring and antifungal development.
Long Non-Coding RNA and Antifungal Susceptibility
The third paper identified a long non-coding RNA that appears to influence triazole susceptibility in Aspergillus fumigatus.
Long non-coding RNAs are molecules that do not produce proteins themselves but can still influence how genes are switched on or off.
Although these molecules are increasingly recognised as important regulators of biological processes, their role in fungal antifungal susceptibility remains relatively unexplored.
The researchers found that altering the activity of a specific long non-coding RNA changed how the fungus responded to azole antifungal drugs in laboratory experiments and animal models.
This is still early-stage science and has no immediate impact on patient treatment. However, it provides another example of how fungal responses to antifungal drugs may be regulated by multiple biological pathways.
Evidence strength: Moderate to strong mechanistic evidence.
Practice-changing now? No.
Bottom line: These studies suggest that antifungal treatment response is influenced by much more than classic resistance mutations. Scientists are uncovering a complex network of stress responses, metabolic adaptations and gene regulation mechanisms that may help Aspergillus survive antifungal exposure. While this research will not change treatment today, it may eventually lead to better ways of predicting, preventing and overcoming antifungal resistance.
Also Noted This Week
Breakthrough Aspergillosis Despite Prophylaxis
A case report described tracheobronchial aspergillosis developing in a lung transplant recipient despite receiving combined antifungal prophylaxis. The infection involved Aspergillus calidoustus and Aspergillus niger.
While only a single case, it serves as a reminder that prophylactic treatment reduces risk but cannot eliminate it completely, particularly in highly immunosuppressed patients and where less common or resistant Aspergillus species may be involved.
Evidence strength: Case report. Clinically notable, but very low-level evidence.
Practice-changing now? No.
Read more:
View on PubMed |
Read via DOI
Therapeutic Drug Monitoring Remains Important
A bibliometric review highlighted growing interest in antifungal therapeutic drug monitoring (TDM).
Therapeutic drug monitoring means measuring antifungal drug levels in the blood to help ensure that treatment is high enough to be effective while minimising toxicity and drug interactions.
This does not provide new clinical trial evidence, but it supports the growing importance of antifungal stewardship, pharmacokinetic monitoring, toxicity prevention and pharmacy-led optimisation of antifungal treatment.
Evidence strength: Bibliometric and service-focused review.
Practice-changing now? No, but relevant to service development and pharmacy practice.
Read more:
View on PubMed |
Read via DOI
Potential Future Drug Targets
A bioRxiv preprint investigated the mannitol biosynthesis pathway in Aspergillus fumigatus, focusing on mannitol-2-dehydrogenase as a possible antifungal target.
This is early preclinical research and does not affect current treatment. However, it is worth watching as part of wider efforts to identify fungal-specific metabolic vulnerabilities that could eventually support new antifungal strategies.
Evidence strength: Preclinical antifungal-target discovery.
Practice-changing now? No. Interesting, but very early.
Read more:
Search bioRxiv for this preprint
Why This Research Matters
- Diagnosis continues to improve through molecular testing.
- Researchers are exploring less invasive options for managing aspergilloma.
- COVID-19-associated pulmonary aspergillosis remains an important complication of severe COVID-19.
- Scientists are discovering new mechanisms that help Aspergillus survive antifungal treatment.
- Future antifungal therapies may target fungal stress responses as well as traditional resistance mechanisms.
What Researchers Will Be Watching Next
- Whether bronchoscopic aspergilloma removal can be replicated in larger studies and specialist centres.
- How PCR testing can be integrated most effectively into routine diagnostic pathways.
- Whether CAPA rates continue to change as COVID-19 evolves and vaccination remains widespread.
- How fungal tolerance contributes to treatment failure and acquired azole resistance.
- Whether new antifungal drugs can exploit pathways such as mannitol metabolism, stress adaptation and epigenetic regulation.
What This Means for Patients
This week's research illustrates how aspergillosis science is advancing in two important directions at the same time.
Firstly, researchers are developing better ways to diagnose and manage disease through improved testing and new interventional approaches.
Secondly, scientists are learning much more about the biology of Aspergillus itself, particularly how it survives antifungal treatment and adapts to stressful environments.
Although none of these studies should change individual treatment decisions today, they contribute to a growing body of knowledge that may improve diagnosis, monitoring and treatment options in the future.
The most immediate clinical relevance comes from studies investigating diagnosis and management. The laboratory studies are less likely to affect care in the short term but may contribute to future advances in treatment and resistance prevention.
For now, the main message is that aspergillosis remains a complex condition that requires specialist assessment and interpretation of test results within the wider clinical picture.
None of the papers discussed in this update support changing treatment without specialist medical advice.
When to Speak to Your Clinical Team
Contact your clinical team promptly if you experience:
- Significant haemoptysis (coughing up blood)
- Worsening breathlessness
- Persistent fever
- New or worsening chest pain
- Severe side effects from antifungal treatment
- New confusion or sudden deterioration
- A sudden worsening of your usual aspergillosis symptoms
Do not stop, reduce, or change antifungal treatment without discussing it with your healthcare team first.
If you cough up a large amount of blood, have severe breathlessness, chest pain, collapse, or feel acutely unwell, seek urgent medical help.
Evidence Strength Summary
| Topic | Evidence type | Clinical relevance | Practice-changing now? |
|---|---|---|---|
| Bronchoscopic aspergilloma removal in post-tuberculosis CPA | Clinical interventional study | Medium to high | No |
| Real-time PCR for invasive aspergillosis | Diagnostic utility study | Moderate | No |
| CAPA umbrella review | Evidence synthesis | High | No |
| Iron starvation and azole tolerance | Mechanistic study | Medium | No |
| Epigenetic azole tolerance | Mechanistic study | Medium to high | No |
| Long non-coding RNA and triazole susceptibility | Mechanistic study | Medium | No |
| Breakthrough tracheobronchial aspergillosis case report | Case report | Low to moderate | No |
| Antifungal therapeutic drug monitoring | Bibliometric/service review | Moderate for services | No |
| Mannitol pathway preprint | Preclinical target discovery | Low at present | No |
Frequently Asked Questions
What is azole tolerance in Aspergillus?
Azole tolerance describes the ability of some Aspergillus cells to survive exposure to antifungal drugs without possessing the classic resistance mutations normally associated with azole resistance. Researchers believe tolerance may sometimes contribute to persistent infection and could provide an opportunity for more stable resistance to develop later.
Can PCR diagnose aspergillosis?
Polymerase chain reaction (PCR) testing can help detect Aspergillus genetic material and may support diagnosis, particularly when combined with imaging, culture, galactomannan testing and clinical assessment. PCR alone cannot confirm invasive disease.
What is COVID-19-associated pulmonary aspergillosis (CAPA)?
COVID-19-associated pulmonary aspergillosis, or CAPA, is a form of aspergillosis that can occur in some patients with severe COVID-19, particularly those requiring intensive care treatment.
Can aspergilloma be removed without surgery?
Research is exploring bronchoscopic removal of aspergilloma in carefully selected patients. However, this remains a specialist procedure and is not currently considered standard treatment. Further studies are needed to determine which patients benefit most.
Does antifungal resistance mean treatment will stop working?
Not necessarily. Many patients respond well to antifungal treatment. Resistance is only one factor influencing treatment success. Drug levels, immune function, disease severity and fungal tolerance mechanisms may also influence outcomes.
Should I change my antifungal treatment because of these studies?
No. None of the studies discussed in this update support changing treatment without specialist medical advice. Patients should always discuss treatment decisions with their clinical team.
Hot Weather Advice for People Living with Aspergillosis
Key Points
- Hot weather can worsen breathlessness, fatigue and sleep quality.
- Dehydration can make mucus thicker and more difficult to clear.
- People with asthma, bronchiectasis, Chronic Pulmonary Aspergillosis (CPA) and Allergic Bronchopulmonary Aspergillosis (ABPA) may notice increased symptoms during heatwaves.
- Stay hydrated, keep cool and avoid strenuous activity during the hottest part of the day.
- Some antifungal medications can increase sensitivity to sunlight.
- Seek medical advice if symptoms worsen significantly or you develop signs of heat-related illness.
Can Hot Weather Make Aspergillosis Worse?
Yes. Hot weather can worsen symptoms for some people living with aspergillosis.
Heat can increase breathlessness, contribute to dehydration, make mucus thicker
and harder to clear, disturb sleep, and increase fatigue.
People with Chronic Pulmonary Aspergillosis (CPA), Allergic Bronchopulmonary
Aspergillosis (ABPA), bronchiectasis, asthma, or adrenal insufficiency may need
to take extra precautions during heatwaves.
Why Heat Can Affect Breathing
When temperatures rise, the body works harder to keep cool. This increases demand
on the heart and lungs and can make breathing feel more difficult.
- Increased breathing rate
- Worsening breathlessness
- Increased fatigue
- More difficult airway clearance
- Poorer sleep
- Reduced exercise tolerance
Stay Well Hydrated
Good hydration is one of the most important steps you can take during hot weather.
Dehydration can make sputum thicker and harder to clear, particularly for people
with bronchiectasis or Chronic Pulmonary Aspergillosis (CPA).
- Drink regularly throughout the day.
- Carry water when travelling.
- Increase fluid intake if sweating heavily.
- Avoid waiting until you feel thirsty before drinking.
Signs of dehydration may include:
- Dark urine
- Dizziness or light-headedness
- Headache
- Dry mouth
- Increased fatigue
- Thick, sticky sputum
If you have heart failure, severe kidney disease or have been advised to restrict
fluids, follow the guidance provided by your healthcare team.
Keep Your Home Cool
- Close curtains and blinds during the day.
- Open windows overnight when temperatures fall.
- Use fans to improve airflow.
- Spend time in the coolest room of the house.
- Avoid ovens and other heat-producing appliances during the hottest periods.
Plan Activities Carefully
Try to avoid strenuous activity between approximately 11am and 4pm when
temperatures are highest.
- Walk early in the morning or later in the evening.
- Take frequent breaks.
- Pace yourself.
- Ask for help with physically demanding tasks during the hottest days.
Medication Considerations
Inhalers
Continue taking inhalers exactly as prescribed. Carry reliever inhalers when away
from home and avoid leaving inhalers in hot cars or direct sunlight.
Antifungal Medicines and Sunlight
Some antifungal medicines can increase sensitivity to sunlight. This is
particularly important for people taking voriconazole.
- Use high-factor sunscreen.
- Wear a hat and protective clothing.
- Avoid prolonged exposure to direct sunlight.
- Report new or changing skin lesions to your healthcare team.
Adrenal Insufficiency
People with adrenal insufficiency may be more vulnerable to dehydration, low blood
pressure and heat-related illness.
- Maintain good hydration.
- Carry steroid emergency information.
- Follow sick-day guidance if you become unwell.
- Seek urgent medical advice if you cannot keep fluids or medication down.
Air Quality Matters Too
Hot weather is often associated with increased pollen levels, elevated ozone
pollution, wildfire smoke or other poor air-quality episodes. These can aggravate
asthma, bronchiectasis and aspergillosis-related respiratory symptoms.
- Check local air-quality forecasts if symptoms worsen.
- Consider staying indoors during peak pollution periods.
- Keep rescue medication available.
Protect Your Sleep
- Use lightweight bedding.
- Close curtains during the day.
- Use a fan at night if helpful.
- Keep water nearby.
- Cool wrists or feet with cool water before bed.
When to Seek Medical Advice
Do not assume that worsening symptoms are always caused by the heat. Seek medical
advice if you experience:
- Markedly worsening breathlessness
- New chest pain
- A significant fall in oxygen saturation, if monitored
- Confusion or fainting
- High fever
- Inability to clear sputum
- Severe weakness
- Vomiting or inability to keep fluids down
Seek urgent medical attention for severe breathing difficulties, collapse, or
signs of heatstroke.
Hot Weather Checklist
- Drink regularly throughout the day.
- Keep cool indoors.
- Avoid strenuous activity during peak heat.
- Monitor breathlessness and sputum changes.
- Continue medicines as prescribed.
- Protect your skin if taking voriconazole.
- Check air-quality forecasts.
- Keep bedrooms cool.
- Seek medical advice if symptoms worsen unexpectedly.
Further Information and Trusted Resources
General Hot Weather Advice
- NHS: How to cope in hot weather
- NHS: Heat exhaustion and heatstroke
- UK Health Security Agency: Beat the Heat
- UKHSA Heat Health Alerts
Related Aspergillosis.org Resources
- Living Well with Aspergillosis
- Managing Breathlessness
- Bronchiectasis and Aspergillosis
- Air Pollution and Lung Health
- Travelling with Aspergillosis
- Exercise, Fatigue and Energy Management
- Adrenal Insufficiency and Steroid Treatment
Frequently Asked Questions
Can hot weather make aspergillosis symptoms worse?
Yes. Heat can worsen breathlessness, fatigue, dehydration and sleep quality, all
of which may make symptoms feel more severe.
Why is hydration so important?
Dehydration can make mucus thicker and more difficult to clear, potentially
worsening cough and breathlessness.
Does hot weather affect Allergic Bronchopulmonary Aspergillosis (ABPA)?
Some people with Allergic Bronchopulmonary Aspergillosis (ABPA) find that heat,
pollen and poor air quality can aggravate asthma symptoms and increase
breathlessness.
Does hot weather affect Chronic Pulmonary Aspergillosis (CPA)?
People with Chronic Pulmonary Aspergillosis (CPA) may notice increased fatigue,
breathlessness and difficulty clearing sputum during hot weather, particularly if
they become dehydrated.
Should I avoid going outside?
Not necessarily. However, avoiding strenuous activity during the hottest part of
the day is often sensible, especially if you have significant lung disease.
What if I take voriconazole?
Voriconazole can increase sensitivity to sunlight. Extra sun protection is
recommended during hot weather.
When to Seek Medical Help
Contact your healthcare team if you experience worsening respiratory symptoms,
increasing fatigue, difficulty clearing sputum, or concerns about dehydration.
Seek urgent medical attention for severe breathing difficulties, collapse,
confusion, or suspected heatstroke.
Author: National Aspergillosis Centre (NAC)
Last reviewed: June 2026
Next review: June 2027
Has My Omalizumab Stopped Working? Understanding Worsening Symptoms, Infections and Flare-Ups in Asthma and ABPA
Last reviewed: June 2026
Key Points
- Omalizumab can remain effective for many years.
- Worsening symptoms do not automatically mean the treatment has stopped working.
- Increasing chest infections may be caused by bronchiectasis, bacterial infection, mucus plugging or another lung condition.
- Asthma and Allergic Bronchopulmonary Aspergillosis (ABPA) can change over time.
- Biologics are usually one part of a wider treatment plan and do not replace inhalers, airway clearance or routine monitoring.
- A specialist review may include blood tests, sputum cultures, lung function tests and CT imaging.
Contents
- Why patients ask this question
- What is omalizumab?
- Does omalizumab wear off?
- Why symptoms may worsen after years of treatment
- What else could be going on?
- Possible reasons for worsening symptoms
- The role of bronchiectasis and infection
- Don't forget the basics
- What tests might help?
- Questions to ask your specialist
- Frequently asked questions
- When to seek medical advice
- The bottom line
Why Patients Ask This Question
Many people living with severe asthma or Allergic Bronchopulmonary Aspergillosis (ABPA) experience major improvements after starting omalizumab. They may have fewer flare-ups, require fewer courses of oral steroids and enjoy a much better quality of life.
However, some patients notice that after several years they begin needing more antibiotics, more steroid courses or more medical reviews. Symptoms such as cough, sputum production, wheeze or breathlessness may start to increase again.
This often leads to a worrying question:
"Has my biologic stopped working?"
In reality, the answer is often more complicated than a simple yes or no.
What Is Omalizumab?
Omalizumab (Xolair®) is a biologic medication that targets immunoglobulin E (IgE), an antibody involved in allergic inflammation.
It is commonly used to treat severe allergic asthma and is also used in some patients with ABPA where allergic inflammation is an important part of the disease.
By reducing IgE activity, omalizumab can help reduce asthma exacerbations, improve symptom control and reduce the need for oral corticosteroids in many patients.
Does Omalizumab Wear Off?
Current evidence suggests that omalizumab can remain effective for many years. Studies following patients with severe allergic asthma have shown sustained benefits in many people over five years or more.
There is currently no strong evidence that most patients develop predictable tolerance to omalizumab simply because they have been taking it for a long time.
This means that if symptoms worsen after four, five or more years of treatment, specialists will usually look for other explanations before concluding that the medication has stopped working.
Why Symptoms May Worsen After Years of Treatment
There are several reasons why symptoms may worsen despite ongoing biologic treatment.
Lung Damage Can Continue to Cause Problems
Many patients with ABPA also have bronchiectasis. Bronchiectasis is permanent widening and damage of the airways that can develop after repeated inflammation and infection.
Even when allergic inflammation is well controlled, bronchiectasis can still cause:
- Persistent cough
- Sputum production
- Breathlessness
- Fatigue
- Recurrent chest infections
In these situations, the biologic may still be helping while another aspect of the lung disease becomes more important.
Infection May Become More Important
Patients with bronchiectasis are more vulnerable to chest infections. Symptoms caused by infection can sometimes look very similar to an asthma or ABPA flare.
Signs suggesting infection may include:
- Increased sputum production
- Darker or thicker sputum
- Fever
- Feeling generally unwell
- More frequent need for antibiotics
Asthma and ABPA Can Change Over Time
Asthma is not a single disease. The pattern of inflammation in the airways may change over time.
Some patients who initially respond very well to anti-IgE treatment may later develop different patterns of airway inflammation, mucus production or airway remodelling.
This is one reason why specialists sometimes review whether a different biologic may be appropriate.
What Else Could Be Going On?
When symptoms worsen after several years of successful biologic treatment, specialists often look beyond asthma and ABPA alone.
Several different conditions can cause cough, breathlessness, sputum production, fatigue and recurrent chest infections.
Bronchiectasis Progression
Even if allergic inflammation is well controlled, bronchiectasis can continue to cause mucus retention, recurrent infections and worsening respiratory symptoms.
Bacterial Infection
Repeated chest infections can become a major cause of symptoms. Common bacteria include:
- Pseudomonas aeruginosa
- Haemophilus influenzae
- Staphylococcus aureus
- Moraxella catarrhalis
Mucus Plugging
Thick mucus can block airways, causing cough, breathlessness and reduced airflow.
Aspergillus Bronchitis
Some patients develop persistent airway infection with Aspergillus species. Symptoms may include chronic productive cough, increased sputum and recurrent respiratory symptoms.
Chronic Pulmonary Aspergillosis (CPA)
Although less common, some patients with previous lung damage may develop chronic pulmonary aspergillosis. Symptoms can include fatigue, weight loss, chronic cough and sometimes coughing up blood.
Nontuberculous Mycobacterial (NTM) Infection
Patients with bronchiectasis may be at increased risk of infection caused by environmental mycobacteria.
Changing Asthma Biology
The type of airway inflammation present when treatment begins may change over time.
The important point is that worsening symptoms do not automatically mean that omalizumab has stopped working.
Several different conditions may produce similar symptoms and require different treatments.
Possible Reasons for Worsening Symptoms
| Possible Cause | Typical Clues |
|---|---|
| ABPA flare | Increasing asthma symptoms, rising IgE, worsening inflammation |
| Bronchiectasis progression | More sputum, recurrent infections, increasing need for airway clearance |
| Bacterial infection | Change in sputum colour, fever, feeling unwell, antibiotics helping |
| Mucus plugging | Sudden worsening breathlessness, blocked airways |
| Aspergillus bronchitis | Persistent productive cough and sputum despite standard treatment |
| Chronic Pulmonary Aspergillosis (CPA) | Weight loss, fatigue, chronic symptoms, coughing up blood |
| NTM infection | Gradual worsening symptoms despite repeated treatment courses |
The Role of Bronchiectasis and Infection
For many patients with ABPA, the most useful question is not:
"Has omalizumab stopped working?"
but rather:
"What is causing my recent increase in symptoms and infections?"
If the main change is increasing antibiotic use, sputum production or recurrent chest infections, the focus may need to shift towards understanding what is happening within the airways.
This may include reviewing sputum cultures, airway clearance techniques, physiotherapy, exercise levels and bronchiectasis management plans.
Don't Forget the Basics
One of the challenges of successful biologic treatment is that patients often feel so much better that other aspects of their disease can gradually receive less attention.
This is completely understandable. When symptoms improve, it is natural to focus less on daily disease management.
However, biologics such as omalizumab do not cure asthma, bronchiectasis or ABPA. They help control specific parts of these conditions.
For example, omalizumab may reduce allergic inflammation and asthma exacerbations, but it does not reverse existing bronchiectasis, remove mucus from the airways or prevent every chest infection.
Think of your lung health as a garden. Omalizumab may be very effective at controlling one type of weed, but the garden still needs regular maintenance. If that maintenance stops, other problems can gradually take over.
Continuing to Manage Your Lung Health
- Take prescribed inhalers regularly.
- Continue airway clearance techniques if recommended.
- Stay physically active within your abilities.
- Monitor changes in sputum volume, colour or thickness.
- Attend routine specialist reviews.
- Keep vaccinations up to date.
- Follow asthma and bronchiectasis action plans where provided.
- Report increasing breathlessness, cough or infections promptly.
Biologics can be highly effective, but they work best as part of a broader management plan rather than replacing it.
The Bottom Line
If symptoms worsen after several years on omalizumab, it does not automatically mean the medication has stopped working.
In patients with asthma and ABPA, increasing antibiotics and steroid use may reflect changing asthma control, ABPA activity, bronchiectasis-related infection, mucus plugging or another lung condition.
Successful biologic treatment can sometimes make it easy to forget that asthma, bronchiectasis and ABPA still require ongoing management. Continuing inhalers, airway clearance, exercise, monitoring and regular review remains important even when symptoms have improved.
A careful specialist review can often identify what has changed and guide the most appropriate next steps.
About the National Aspergillosis Centre (NAC)
The UK's specialist centre for aspergillosis
The National Aspergillosis Centre (NAC) is a specialist NHS service based at Wythenshawe Hospital in Manchester, part of Manchester University NHS Foundation Trust.
NAC provides expert assessment, diagnosis, treatment and long-term management for people with complex forms of aspergillosis, particularly Chronic Pulmonary Aspergillosis (CPA). The centre also supports healthcare professionals across the United Kingdom with specialist advice, guidance and multidisciplinary case discussion.
Alongside its clinical work, NAC supports research, education and patient engagement, helping improve understanding and care of aspergillosis nationally and internationally.
National Aspergillosis Centre at a glance
| Service | National Aspergillosis Centre (NAC) |
| Location | Wythenshawe Hospital, Manchester |
| Organisation | Manchester University NHS Foundation Trust |
| Specialty | Complex aspergillosis care |
| National role | NHS specialist referral service |
| Supports | Patients and healthcare professionals across the UK |
What is aspergillosis?
Aspergillosis is a group of conditions caused by fungi from the Aspergillus family. These fungi are commonly found in the environment, and most people breathe in Aspergillus spores every day without becoming ill.
In some circumstances, however, Aspergillus can cause disease. This may occur because of underlying lung disease, asthma or allergic conditions, a weakened immune system, structural lung damage or previous lung infections.
Which conditions does NAC help manage?
Chronic Pulmonary Aspergillosis (CPA)
CPA is a long-term fungal infection of the lungs that can develop in people who already have lung damage or cavities caused by previous illness.
Allergic Bronchopulmonary Aspergillosis (ABPA)
ABPA is an allergic reaction to Aspergillus that most commonly affects people with asthma or cystic fibrosis.
Aspergillus bronchitis
Aspergillus bronchitis is a chronic airway infection in which Aspergillus is repeatedly identified in the airways and contributes to ongoing respiratory symptoms.
Other complex Aspergillus-related conditions
- Aspergillus nodules
- Severe Asthma with Fungal Sensitisation (SAFS)
- complex diagnostic cases
- difficult-to-treat aspergillosis
- antifungal treatment complications
- therapeutic drug monitoring
Not all patients with aspergillosis need referral to NAC. Many people receive excellent care through local respiratory, infectious diseases, allergy or severe asthma services.
How do referrals work?
Patients are normally referred by a healthcare professional. Referrals may come from respiratory physicians, infectious diseases specialists, immunologists, severe asthma services or general practitioners working with specialist teams.
NAC also supports clinicians through remote advice services and multidisciplinary discussions, helping many patients receive specialist input without needing regular travel to Manchester.
What happens at a NAC appointment?
Every patient is different, but assessment may include:
- review of symptoms and medical history
- review of computed tomography (CT) scans and other imaging
- blood test review
- review of microbiology and fungal test results
- assessment of antifungal treatment
- therapeutic drug monitoring
- discussion of future treatment options
Patients often continue to receive much of their care locally, with specialist recommendations provided by NAC.
Specialist aspergillosis care across the UK
Although NAC is the UK's national specialist centre for chronic aspergillosis, specialist care is also provided through many hospitals and specialist services across the country.
Depending on the condition involved, patients may receive care from respiratory medicine services, bronchiectasis clinics, severe asthma centres, infectious diseases departments, allergy services or immunology services.
The most appropriate service depends on the type of aspergillosis and the patient's individual circumstances.
Research and innovation
Research is a central part of the work carried out by NAC and its partners. Areas of ongoing research include improved diagnostics, new antifungal medications, biologic therapies, therapeutic drug monitoring, imaging, disease monitoring, patient experience and clinical trials.
Education and patient support
The National Aspergillosis Centre is committed to helping patients and carers understand their condition and access reliable information.
Resources available through aspergillosis.org include:
- over 1,000 patient information articles
- condition-specific Knowledge Hubs
- support meetings
- recorded educational talks
- patient stories
- research updates
- guidance for carers and families
Working together
Effective aspergillosis care relies on collaboration between patients, carers, local healthcare teams and specialist services.
NAC works closely with healthcare professionals, researchers, patient organisations and charities to improve awareness, diagnosis, treatment and support for people living with aspergillosis.
Frequently asked questions
What is the National Aspergillosis Centre?
The National Aspergillosis Centre is a specialist NHS service based at Wythenshawe Hospital in Manchester. It provides expert care and advice for complex forms of aspergillosis, especially Chronic Pulmonary Aspergillosis.
Where is NAC located?
NAC is based at Wythenshawe Hospital in Manchester, part of Manchester University NHS Foundation Trust.
Who can be referred to NAC?
Patients with complex or difficult-to-manage aspergillosis may be referred by a healthcare professional. Many referrals involve Chronic Pulmonary Aspergillosis, but NAC also provides advice for other Aspergillus-related conditions.
Can I refer myself to NAC?
Patients are normally referred by a healthcare professional. If you believe specialist input may be helpful, discuss this with your clinical team.
Do I have to live near Manchester?
No. Patients are referred from throughout the United Kingdom, and NAC also supports clinicians remotely.
Does everyone with aspergillosis need NAC?
No. Many patients are managed successfully by local specialist teams. NAC is primarily involved in complex cases and specialist advice.
Does NAC only treat CPA?
No. Although NAC is especially known for Chronic Pulmonary Aspergillosis, it also provides advice and support for a range of complex Aspergillus-related conditions.
What happens during a NAC appointment?
A NAC appointment may include review of symptoms, scans, blood tests, microbiology results, antifungal treatment, drug levels and future treatment options.
Does NAC provide patient support?
Yes. Through aspergillosis.org and the NAC CARES programme, patients and carers can access educational resources, support meetings and community activities.
Suggested links
- Manchester University NHS FT Aspergillosis for full details, referral
- What is aspergillosis?
- Chronic Pulmonary Aspergillosis (CPA)
- Allergic Bronchopulmonary Aspergillosis (ABPA)
- Aspergillus bronchitis
- Aspergillosis Knowledge Hub
- Find an aspergillosis clinic
- Support meetings and community
- Information for professionals
- Latest articles and research updates
About this page
This page was prepared by the National Aspergillosis Centre CARES team to explain the role of the National Aspergillosis Centre and how specialist aspergillosis care is provided within the UK healthcare system.
Last reviewed: June 2026
Why the UK’s Infection Specialist Workforce Matters to People Living with Aspergillosis
A new national report has called for urgent action to strengthen and modernise the UK’s infection-specialist workforce. The report, Infection Prevention and Management in the UK: The Infection-Specialist Workforce, was published by the Healthcare Infection Society and partner organisations across the infection community.
At first glance, workforce planning may sound like an issue mainly for hospitals, universities, laboratories and policymakers. However, for people living with aspergillosis and other complex fungal diseases, the availability of specialist expertise can directly affect diagnosis, treatment, access to advice and long-term outcomes.
Why this matters to patients
Aspergillosis is not a single disease. It includes conditions such as Allergic Bronchopulmonary Aspergillosis (ABPA), Chronic Pulmonary Aspergillosis (CPA), Aspergillus bronchitis and invasive aspergillosis.
These conditions are often complex, uncommon and difficult to recognise. Many patients describe long journeys to diagnosis, sometimes involving repeated chest infections, worsening asthma, unexplained fatigue, weight loss, breathlessness, abnormal scans or uncertainty about the meaning of test results.
When specialist infection, respiratory, laboratory and mycology expertise is difficult to access, patients may face longer waits for diagnosis, referral and treatment decisions.
Why this matters to professionals
The report highlights the central role of the infection-specialist workforce in clinical care, diagnostics, infection prevention and control, antimicrobial stewardship, public health and system preparedness.
This workforce includes infectious diseases physicians, clinical microbiologists, virologists, medical mycologists, infection prevention specialists, specialist nurses, antimicrobial pharmacists, biomedical scientists and clinical scientists.
For fungal disease, this multidisciplinary expertise is essential. Diagnosing and managing aspergillosis often requires careful interpretation of clinical history, imaging, fungal culture, Aspergillus antibody testing, galactomannan, molecular diagnostics, antifungal drug levels, susceptibility results and treatment toxicity monitoring.
What workforce shortages can mean in practice
For patients with aspergillosis, workforce pressures may contribute to:
- Delays in recognising possible fungal disease.
- Delays in referral to specialist services.
- Variation in access to expertise between regions.
- Longer waits for interpretation of specialist tests.
- Reduced capacity for multidisciplinary team discussion.
- Greater pressure on specialist centres and laboratories.
- Delays in accessing newer diagnostics, antifungal treatments or clinical trials.
For professionals, these pressures can make already complex work more difficult. Clinicians may be managing patients with rare fungal disease alongside heavy general respiratory, microbiology, infectious diseases or laboratory workloads. Specialist advice networks and reference services therefore become increasingly important.
The importance of medical mycology
Fungal diseases remain under-recognised compared with many bacterial and viral infections, despite causing serious illness in people with chronic lung disease, immune suppression, transplantation, cancer treatment or prolonged critical illness.
Medical mycology is a highly specialised area. It supports accurate diagnosis, antifungal treatment selection, interpretation of complex tests and recognition of emerging resistance. Without sufficient mycology expertise, advances in fungal diagnostics and treatment may not reach patients quickly or consistently.
The role of specialist centres
The UK benefits from specialist services such as the National Aspergillosis Centre, which provides expert assessment, multidisciplinary review and advice for patients with complex forms of aspergillosis.
However, specialist centres cannot work in isolation. Earlier recognition by GPs, respiratory teams, radiologists, microbiologists, infectious diseases teams and local laboratories is vital. Strong referral pathways help patients reach the right expertise at the right time.
For rare fungal diseases, national specialist centres and local services need to function as part of a connected system rather than as separate parts of care.
A patient safety and equity issue
Access to infection expertise is also an equity issue. Patients should not face very different chances of diagnosis or specialist input depending on where they live.
Strengthening the infection-specialist workforce could help reduce variation in care, support earlier diagnosis and improve access to expert advice across the UK.
Looking ahead
New antifungal drugs, improved diagnostics, molecular testing, genomics and clinical trials are creating new opportunities to improve aspergillosis care.
But innovation only helps patients if there are trained professionals available to recognise fungal disease, request appropriate tests, interpret results, prescribe and monitor treatment, and work across multidisciplinary teams.
For patients and professionals alike, the message is clear: strengthening the UK’s infection-specialist workforce is not simply a staffing issue. It is essential for earlier diagnosis, safer treatment, better access to expertise and more equitable care for people living with complex fungal diseases.
What does this mean for people living with aspergillosis?
- Specialist expertise can help shorten the journey to diagnosis.
- Better workforce capacity can improve access to advice and referral.
- Strong laboratory services are essential for accurate fungal diagnosis.
- Medical mycology expertise helps guide safe and effective treatment.
- More consistent access to specialist care could reduce regional inequality.
Further reading
- Healthcare Infection Society: Infection Specialist Workforce Report
- Royal College of Pathologists: New report calls for urgent action to strengthen the UK’s infection specialist workforce
Frequently Asked Questions
Why are infection specialists important for aspergillosis?
Aspergillosis can be difficult to diagnose and manage. Infection specialists, respiratory clinicians, microbiologists and medical mycologists help identify fungal disease, interpret specialised tests and guide treatment decisions.
What is medical mycology?
Medical mycology is the branch of medicine and laboratory science concerned with fungal diseases affecting humans. Specialists in medical mycology help diagnose and manage infections caused by fungi such as Aspergillus.
Why can aspergillosis take a long time to diagnose?
The symptoms of aspergillosis often overlap with those of more common respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis and recurrent chest infections. Specialist investigations and expert interpretation are frequently required.
How could workforce shortages affect patients?
Workforce shortages may contribute to delays in diagnosis, referral and access to specialist advice. They can also place additional pressure on laboratories, multidisciplinary teams and specialist centres.
What role do specialist laboratories play?
Specialist laboratories perform fungal cultures, Aspergillus antibody testing, antigen testing, molecular diagnostics and antifungal susceptibility testing. These investigations are often essential for accurate diagnosis and treatment planning.
What is the National Aspergillosis Centre?
The National Aspergillosis Centre (NAC) is a UK specialist service providing expert assessment, multidisciplinary review and management advice for patients with complex aspergillosis.
Will new treatments solve these problems?
New antifungal medicines and diagnostic technologies offer significant opportunities to improve care. However, trained healthcare professionals are still needed to recognise disease, request investigations, interpret results and monitor treatment safely.
How can patients help improve awareness of aspergillosis?
Patients can help by sharing reliable information, supporting awareness campaigns, participating in patient groups and, where appropriate, contributing to research and patient involvement activities.
Last reviewed: June 2026
Suggested audience: Patients, carers, respiratory clinicians, infectious diseases clinicians, microbiologists, medical mycologists, specialist nurses, pharmacists, biomedical scientists, clinical scientists, commissioners and service planners.
Aspergillus Otomycosis: A 2026 Update for Clinicians and Expert Patients
Article type: Clinical and expert-patient evidence updateIntended audience: Ear, nose and throat clinicians, infectious diseases specialists, medical mycologists, general practitioners, specialist nurses, expert patients and carers.Last reviewed: June 2026
Key points
- Otomycosis is a fungal infection of the external auditory canal. It is often described as fungal otitis externa.
- Aspergillus species and Candida species are the most commonly reported causes.
- Older reports often describe Aspergillus niger as the main cause, but molecular methods show that related black Aspergillus species, including Aspergillus tubingensis, may previously have been misidentified as A. niger.
- Diagnosis is usually clinical, supported where possible by microscopy, fungal culture and species identification.
- Successful treatment usually requires careful cleaning of the ear canal as well as appropriate topical antifungal treatment.
- Before topical treatment is used, clinicians should assess whether the tympanic membrane is intact, because some preparations may be unsafe if there is perforation, grommets, a mastoid cavity or previous ear surgery.
- Most cases are superficial, but recurrent, severe or treatment-resistant disease should prompt reassessment for mixed bacterial infection, diabetes, immunosuppression, hearing aid moulds, foreign body, chronic ear disease or extension beyond the external canal.
- Invasive or necrotising external otitis is rare but serious and requires urgent specialist assessment.
- Sudden hearing loss, facial weakness, severe persistent pain, mastoid swelling or tenderness, neurological symptoms, or infection in a person with diabetes or significant immunosuppression should be treated as red flags.
Contents
- What is otomycosis?
- Aspergillus ear infection is different from lung aspergillosis
- Why Aspergillus matters
- Epidemiology and why cases may be missed
- Causative Aspergillus species
- Risk factors
- Symptoms and clinical features
- Diagnosis
- Differential diagnosis
- Treatment principles
- Recurrent or treatment-resistant otomycosis
- Invasive Aspergillus ear infection and necrotising external otitis
- Practical advice for patients
- Frequently asked questions
- When to seek urgent medical help
- Evidence gaps and uncertainty
- References
What is otomycosis?
Otomycosis is a fungal infection of the external auditory canal, the skin-lined passage leading from the outer ear to the eardrum. It is also called fungal otitis externa. The infection may be acute, subacute or chronic, and it can be mistaken for bacterial otitis externa, eczema, wax, chronic discharge or non-specific inflammation.
In most people, otomycosis is a superficial infection of the outer ear canal. It can be uncomfortable, persistent and prone to recurrence, but it is usually treatable when the ear is examined, cleaned and treated appropriately. Rarely, particularly in people with diabetes, immunosuppression, previous ear surgery or severe persistent symptoms, infection may spread beyond the ear canal and become invasive.
Plain-English summary: most Aspergillus ear infections affect the outer ear canal. They are usually not the same as invasive aspergillosis in the lungs or bloodstream, but they can still need specialist ear care to clear the infection safely.
Aspergillus ear infection is different from lung aspergillosis
Many people searching online for Aspergillus find information about chronic pulmonary aspergillosis, allergic bronchopulmonary aspergillosis or invasive aspergillosis. These are different conditions.
Aspergillus otomycosis usually affects the external ear canal only. It is usually a local fungal infection rather than a whole-body infection. It does not usually mean that a person has invasive aspergillosis, chronic pulmonary aspergillosis or allergic bronchopulmonary aspergillosis.
However, people with existing lung disease, diabetes, immune suppression or complex medical histories should still tell their clinician about these conditions, because they may affect assessment and treatment decisions.
Why Aspergillus matters
Aspergillus is a common environmental mould. Its spores are present in air, dust, soil, compost, decaying vegetation and indoor environments. In the ear canal, fungal growth is favoured when local conditions change. Moisture, trauma to the skin, loss of normal wax protection, altered acidity, previous antibiotic or steroid drops, retained debris and obstruction from hearing aid moulds or ear plugs can all make fungal overgrowth more likely.
In otomycosis, Aspergillus species are among the most frequently reported fungi. They are particularly important because their appearance in the ear can be striking, with black, grey, greenish, yellow-white or fluffy debris. However, appearance alone is not enough for precise species identification.
Epidemiology and why cases may be missed
Reported prevalence varies considerably between studies and geographical regions. Otomycosis is more common in some warm, humid or dusty environments, but it is reported worldwide, including in the United Kingdom. In UK practice, it may be considered particularly in chronic, recurrent or treatment-resistant otitis externa.
Cases may be missed because symptoms overlap with bacterial otitis externa and inflammatory ear conditions. A patient may be treated repeatedly with antibacterial or steroid-containing ear drops before fungal infection is considered. In some cases, antibacterial treatment may suppress bacteria while allowing fungi to overgrow.
A 2025 systematic review highlighted increasing use of molecular methods for species identification, although many published studies still rely primarily on microscopy and culture.
Causative Aspergillus species
Older articles often refer to Aspergillus niger as the dominant Aspergillus species in otomycosis. This remains a useful clinical shorthand, but it is no longer the whole story. Modern molecular identification has shown that black Aspergillus isolates are a complex group and may include species such as Aspergillus tubingensis and other members of the Aspergillus niger complex.
Reported Aspergillus species in otomycosis and fungal otitis externa include:
- Aspergillus niger complex, including related black Aspergillus species
- Aspergillus tubingensis
- Aspergillus flavus
- Aspergillus fumigatus
- Aspergillus terreus complex, reported occasionally in superficial infection series but apparently less common than the Aspergillus niger complex or Aspergillus flavus
Clinical relevance: species-level identification is not always needed for straightforward cases that respond to topical treatment. It becomes more important in recurrent, invasive, immunocompromised or treatment-resistant infection, or where systemic antifungal treatment is being considered.
Risk factors
Otomycosis usually develops when the normal protective environment of the ear canal is disrupted. Important risk factors include:
- warm, humid or dusty environments
- frequent swimming or repeated water exposure
- use of cotton buds, ear picking or other trauma to the ear canal
- previous or repeated antibacterial ear drops
- topical steroid use in the ear
- hearing aids, ear plugs or occlusive moulds
- excess wax, retained debris or foreign material
- chronic otitis externa or chronic otitis media
- previous ear surgery or mastoid cavity
- tympanic membrane perforation
- diabetes, especially if poorly controlled
- immunosuppression, including chemotherapy, transplant medicines, prolonged high-dose corticosteroids and some biological therapies
- skin conditions affecting the ear canal, such as eczema or seborrhoeic dermatitis
Plain-English summary: fungi grow more easily when the ear canal is damp, damaged, blocked, repeatedly treated with antibiotics, or when a person’s immune defences are reduced.
Symptoms and clinical features
Symptoms vary. Some patients have mild itching and fullness, while others have marked discomfort, discharge or hearing loss. Common symptoms include:
- itching in the ear
- ear fullness or blockage
- discharge from the ear
- reduced hearing, often due to debris blocking the canal
- ear discomfort or pain
- tinnitus or ringing in the ear
- scaling, inflammation or visible debris in the ear canal
Severe pain, persistent night pain, swelling around the ear, tenderness or swelling over the mastoid bone behind the ear, fever, persistent or severe dizziness, facial weakness, severe headache, cranial nerve symptoms or symptoms in a person with diabetes or immunosuppression should raise concern for more serious disease.
Sudden hearing loss should be treated as a medical emergency and assessed urgently, regardless of whether otomycosis is suspected.
Diagnosis
Clinical examination
Diagnosis is often suspected by otoscopic or microscopic examination of the ear canal. Typical findings may include fungal debris, spores, hyphae, wet or dry masses, inflammation, scaling, discharge and obstruction. Black, grey, white, yellow-green or fluffy material may be seen, but visual appearance does not reliably identify the species.
Assessment should include:
- extent of external canal inflammation
- presence of fungal debris or discharge
- degree of canal obstruction
- condition of the tympanic membrane
- evidence of perforation, grommets, mastoid cavity or prior surgery
- features suggesting bacterial co-infection
- signs of spread beyond the external canal
Microscopy and fungal culture
Microscopy can demonstrate fungal hyphae or yeast forms. Culture can identify whether Aspergillus, Candida or another fungus is present. Bacterial culture may also be useful if mixed infection is suspected.
Culture is especially helpful when disease is recurrent, severe, atypical, invasive, not responding to standard treatment, or occurring in a person with diabetes, immunosuppression or previous ear surgery.
Molecular identification
Molecular methods can identify Aspergillus species more accurately than morphology alone. This matters because older culture-based reports may have grouped several black Aspergillus species under Aspergillus niger. Molecular identification may also help in epidemiological studies and difficult clinical cases.
For routine mild otomycosis, molecular identification is not always necessary. For persistent, recurrent or invasive disease, species-level identification and antifungal susceptibility testing may help guide treatment.
Antifungal susceptibility testing
Antifungal susceptibility testing is not required for every simple case. It should be considered when there is treatment failure, recurrent disease, unusual species, invasive infection or planned systemic antifungal therapy. Susceptibility patterns may vary between Aspergillus species, although resistance testing is not routinely required for uncomplicated superficial disease.
When to consider imaging
Imaging is not needed for uncomplicated superficial otomycosis. It may be required if there is concern about necrotising external otitis, skull base osteomyelitis, mastoid involvement, middle ear extension, cranial nerve involvement or deep tissue spread. Imaging decisions should be made by ear, nose and throat, infectious diseases, radiology and microbiology or mycology specialists as appropriate.
Differential diagnosis
Conditions that can resemble Aspergillus otomycosis include:
- bacterial otitis externa
- chronic otitis externa
- eczema or dermatitis of the ear canal
- impacted wax
- foreign body
- chronic suppurative otitis media
- cholesteatoma
- otitis media with perforation
- necrotising external otitis
- malignancy of the external canal or temporal bone, rarely
Failure to respond to usual antibacterial treatment should prompt reconsideration of the diagnosis rather than repeated courses of the same treatment.
Treatment principles
Treatment depends on severity, tympanic membrane status, immune status, recurrence, species where known, and whether infection is limited to the outer ear canal. Local ear, nose and throat practice and local antimicrobial guidance should be followed.
1. Aural toilet and debridement
Careful cleaning of the ear canal is central to management. Fungal debris can block the canal, protect organisms from topical treatment and contribute to hearing loss. Aural toilet, often using microsuction or careful debridement, is usually best performed by a trained clinician using appropriate equipment, especially if the canal is swollen, painful, obstructed, or if the tympanic membrane cannot be seen.
Patients should not attempt deep cleaning with cotton buds, hair grips, ear candles or improvised tools. These can damage the ear canal, push debris deeper, worsen inflammation or perforate the eardrum.
Ear irrigation is not usually the preferred approach for suspected otomycosis, because retained moisture may encourage fungal growth and because irrigation may be unsafe if there is tympanic membrane perforation, grommets or previous ear surgery.
2. Topical antifungal treatment
Most uncomplicated otomycosis is treated with topical antifungal therapy after cleaning. Reported agents include clotrimazole, miconazole, nystatin, ciclopirox and other locally used preparations. Different countries and ear, nose and throat services use different formulations, and the evidence does not clearly establish one universally superior topical agent for all cases.
Choice of topical treatment should consider:
- likely organism: mould versus yeast
- whether the tympanic membrane is intact
- previous ear surgery, mastoid cavity or grommets
- local formulary and ear, nose and throat practice
- potential ototoxicity
- patient tolerance and adherence
- whether the canal needs repeat cleaning
3. Tympanic membrane safety
Assessment of the eardrum is important. Some topical agents, antiseptics, acidic preparations or combination drops may be unsafe if the tympanic membrane is perforated or if there are grommets, a mastoid cavity or previous ear surgery. If the eardrum cannot be visualised, treatment should be chosen cautiously and specialist ear, nose and throat advice may be needed.
Important safety point
Patients should not put unprescribed antifungal, antiseptic, acidic, oil-based or herbal preparations into the ear. This is especially important if there is discharge, severe pain, previous ear surgery, grommets, suspected perforated eardrum, sudden hearing loss, dizziness or facial weakness.
4. Mixed bacterial and fungal infection
Mixed infection can occur. If bacterial infection is suspected, bacterial culture and targeted antibacterial treatment may be needed. However, repeated broad-spectrum antibacterial drops without reassessment may encourage fungal overgrowth and delay recognition of otomycosis.
5. Hearing aids, earmoulds and ear plugs
Hearing aids, earmoulds and ear plugs can trap moisture and debris in the ear canal. They may also act as a continuing source of irritation or contamination if not cleaned properly. In recurrent otomycosis, hearing aids and moulds should be reviewed, cleaned according to manufacturer guidance and, where appropriate, assessed by audiology or ear, nose and throat services.
6. Diabetes and immune suppression
People with diabetes or significant immune suppression need particular care, because severe or invasive external ear infection is more likely in these groups. Optimising glycaemic control may help reduce the risk of severe or recurrent infection. Clinicians should consider whether persistent or severe otitis externa in a person with diabetes could represent necrotising external otitis.
7. Systemic antifungal treatment
Systemic antifungal treatment is not usually required for uncomplicated superficial otomycosis. It may be considered in selected situations, including:
- invasive or necrotising external otitis
- extension into the middle ear, mastoid, skull base or surrounding tissues
- severe infection in an immunocompromised patient
- persistent disease where topical therapy is not possible, unsafe or ineffective
- cases requiring multidisciplinary ear, nose and throat, infectious diseases and mycology input
Systemic antifungal choice should be guided by species identification, susceptibility testing, site and extent of infection, drug interactions, renal and liver function, and local specialist advice. Azole antifungals such as itraconazole, voriconazole, posaconazole and isavuconazole have important drug interactions and monitoring requirements.
Recurrent or treatment-resistant otomycosis
Recurrent otomycosis is common in some series. Recurrence does not always mean that the original treatment was wrong; it may reflect ongoing risk factors or incomplete clearance of debris.
When otomycosis recurs or fails to respond, clinicians should reassess:
- Was the ear canal adequately cleaned?
- Can the tympanic membrane be seen?
- Is there perforation, chronic otitis media or mastoid cavity disease?
- Is there a hearing aid mould, ear plug or foreign body contributing?
- Is the patient using cotton buds or self-cleaning the ear?
- Is there persistent water exposure?
- Is there eczema, dermatitis or another inflammatory ear condition?
- Is there mixed bacterial and fungal infection?
- Has microscopy or culture confirmed the organism?
- Is species-level identification or susceptibility testing needed?
- Is the patient diabetic or immunocompromised?
- Is there severe pain, mastoid tenderness or evidence of deeper spread?
Invasive Aspergillus ear infection and necrotising external otitis
Most Aspergillus otomycosis is superficial. However, fungal infection of the external ear can rarely become invasive, particularly in people with diabetes, immunosuppression, severe chronic ear disease or previous ear surgery.
Necrotising external otitis, historically called malignant external otitis, is a severe infection that may involve soft tissues, cartilage, temporal bone or skull base. It is most often bacterial, especially due to Pseudomonas aeruginosa, but fungal cases including Aspergillus and Candida are reported. Fungal necrotising external otitis can be difficult to diagnose and may require prolonged treatment.
Features that should raise concern include:
- severe, persistent or worsening ear pain, especially at night
- pain out of proportion to examination findings
- persistent discharge despite appropriate treatment
- granulation tissue in the ear canal
- facial weakness or other cranial nerve symptoms
- persistent, severe or worsening dizziness, particularly with severe pain, hearing loss or neurological symptoms
- severe headache or neurological symptoms
- swelling, redness or cellulitis around the ear
- tenderness, swelling or redness over the mastoid bone behind the ear
- diabetes, especially if poorly controlled
- immunosuppression
- evidence of mastoid, middle ear or skull base involvement
Suspected invasive or necrotising disease needs urgent ear, nose and throat assessment, microbiological sampling, imaging and specialist antimicrobial or antifungal planning. This is not a condition for self-treatment.
Practical advice for patients and expert patients
Patients can support recovery by protecting the ear canal while treatment is underway. Advice should be individualised by the treating clinician, but common measures include:
- keep the affected ear dry unless advised otherwise
- avoid swimming until cleared by a clinician
- do not use cotton buds or insert objects into the ear
- use prescribed drops exactly as directed
- attend follow-up if symptoms persist, because repeat cleaning may be needed
- tell the clinician about diabetes, immune problems, steroid use, biological therapies, chemotherapy, transplant medicines or previous ear surgery
- ask whether hearing aids, earmoulds or ear plugs need cleaning or review
- report severe pain, dizziness, facial weakness, worsening hearing loss or persistent discharge urgently
Important: online images of invasive aspergillosis can be frightening and often do not represent ordinary otomycosis. Most Aspergillus ear infections are local infections of the outer ear canal. The key is proper assessment, safe cleaning and appropriate treatment.
Frequently asked questions
Is Aspergillus otomycosis rare?
It depends on the setting. Otomycosis is common in some warm and humid regions but is less commonly recognised in many UK clinics. Aspergillus otomycosis may be unfamiliar to clinicians who do not often see fungal ear disease.
Is it the same as invasive aspergillosis?
Usually, no. Most Aspergillus otomycosis is a superficial infection of the outer ear canal. Invasive disease is rare but important, especially in people with diabetes, immunosuppression, severe pain or persistent infection.
Can an ear infection cause symptoms elsewhere in the body?
Otomycosis itself would not usually cause breathlessness, chest symptoms or systemic illness. If a person with suspected otomycosis is also breathless, has chest pain, fever, low oxygen levels or feels very unwell, those symptoms should be assessed separately and promptly.
Can it affect hearing?
Yes. Hearing may be reduced if the ear canal is blocked by fungal debris, discharge or swelling. Hearing often improves when the canal is cleaned and inflammation settles. Sudden hearing loss should be treated as a medical emergency and assessed urgently.
Should every case be cultured?
Not necessarily. Straightforward cases may be treated clinically. Culture and microscopy are more useful when symptoms are recurrent, severe, atypical, treatment-resistant, associated with perforation or surgery, or occur in an immunocompromised patient.
Are antifungal ear drops enough?
Often, topical treatment is effective, but drops may not work well if the ear canal is blocked with debris. Cleaning the canal is often as important as the antifungal medicine itself.
Can patients buy something and treat it themselves?
This is not recommended. Ear symptoms can have several causes, and some substances may be unsafe if the eardrum is perforated. Patients should seek clinical assessment before putting unprescribed antifungal, antiseptic, acidic, herbal or oil-based preparations into the ear.
Why does otomycosis come back?
Recurrence can happen if the canal remains damp, debris persists, the ear is repeatedly traumatised, a hearing aid mould traps moisture, eczema is present, antibiotics are repeatedly used, or an underlying condition such as diabetes or immune suppression is not recognised.
When to seek urgent medical help
Patients should seek urgent medical advice if they have:
- severe or worsening ear pain
- pain that wakes them at night
- swelling, redness or tenderness around the ear
- tenderness, swelling or redness over the mastoid bone behind the ear
- persistent discharge despite treatment
- sudden hearing loss or rapidly worsening hearing
- persistent, severe or worsening dizziness
- severe headache or vomiting
- facial weakness or changes in facial movement
- confusion, fever or feeling very unwell
- diabetes, immune suppression or recent chemotherapy or transplant treatment with ear infection symptoms
- previous ear surgery, grommets or known eardrum perforation with new discharge or pain
These symptoms do not prove invasive infection, but they should be assessed promptly.
Evidence gaps and uncertainty
The evidence base for otomycosis is improving but remains limited. Many studies are single-centre observational series from regions where otomycosis is more common. Treatment studies vary in diagnostic criteria, topical agents, follow-up duration and whether cleaning was standardised. There is no single universally accepted treatment regimen for all cases.
Important gaps include:
- limited high-quality randomised trials comparing topical antifungal treatments
- variable reporting of tympanic membrane status and previous ear surgery
- inconsistent use of fungal culture, molecular identification and susceptibility testing
- limited data on recurrence prevention
- limited evidence specific to UK practice
- uncertainty about the best systemic antifungal approach in rare invasive cases
For these reasons, this article should support but not replace specialist clinical judgement.
References
- Nazari T, Peymaeei F, Ghazi Mirsaid R, et al. Otomycosis: a systematic review and meta-analysis of prevalence and causative agents in the era of molecular diagnostics. BMC Infectious Diseases. 2025;25(1). doi: 10.1186/s12879-025-10954-y. PubMed
- Bojanović M, Stalević M, Arsić-Arsenijević V, et al. Etiology, Predisposing Factors, Clinical Features and Diagnostic Procedure of Otomycosis: A Literature Review. Journal of Fungi. 2023;9(6):662. doi: 10.3390/jof9060662. PubMed
- Wiegand S, Berner R, Schneider A, Lundershausen E, Dietz A. Otitis Externa: Investigation and Evidence-Based Treatment. Deutsches Ärzteblatt International. 2019. doi: 10.3238/arztebl.2019.0224. PubMed
- Koltsidopoulos P, Skoulakis C. Otomycosis With Tympanic Membrane Perforation: A Review of the Literature. Ear, Nose & Throat Journal. 2019;99(8):518–521. doi: 10.1177/0145561319851499. PubMed
- Mtibaa L, Halwani C, El Hamdi M, et al. A retrospective study of 43 cases of fungal malignant external otitis. Pan African Medical Journal. 2022;41. doi: 10.11604/pamj.2022.41.287.29585. PubMed
- Szigeti G, Sedaghati E, Mahmoudabadi AZ, et al. Species assignment and antifungal susceptibilities of black aspergilli recovered from otomycosis cases in Iran. Mycoses. 2011;55(4):333–338. doi: 10.1111/j.1439-0507.2011.02103.x. PubMed
- Jimenez-Garcia L, Celis-Aguilar E, Díaz-Pavón G, et al. Efficacy of topical clotrimazole vs. topical tolnaftate in the treatment of otomycosis: a randomized controlled clinical trial. Brazilian Journal of Otorhinolaryngology. 2020;86(3):300–307. doi: 10.1016/j.bjorl.2018.12.007. PubMed
- Mofatteh MR, Naseripour Yazdi Z, Yousefi M, et al. Comparison of the recovery rate of otomycosis using betadine and clotrimazole topical treatment. Brazilian Journal of Otorhinolaryngology. 2018;84(4):404–409. doi: 10.1016/j.bjorl.2017.04.004. PubMed
- Mao C, Li A, Hu J, et al. Efficient and accurate diagnosis of otomycosis using an ensemble deep-learning model. Frontiers in Molecular Biosciences. 2022;9:951432. doi: 10.3389/fmolb.2022.951432. PubMed
- Feng Y, Zhang Z, Fang W, et al. Profiling Drug Susceptibility and Species Identification of Aspergillus Isolates From Patients With Superficial Infection. Mycoses. 2025;68(4). doi: 10.1111/myc.70059. PubMed
- NICE Clinical Knowledge Summaries. Otitis externa. NICE CKS
Author and review information
Article type: Clinical and expert-patient evidence update
Intended audience: Ear, nose and throat clinicians, infectious diseases specialists, medical mycologists, general practitioners, specialist nurses, patients and carers seeking detailed information.
Last reviewed: June 2026
Review note: This article is for information and education. It should not replace assessment by a qualified clinician. Treatment choices depend on examination findings, tympanic membrane status, culture results where available, medical history, immune status and local prescribing guidance.
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Weekly Aspergillosis Research Update – 15 June 2026
Key Points
- A large population study confirms that people who have survived tuberculosis (TB) have a substantially increased risk of developing chronic pulmonary aspergillosis (CPA).
- New UK data highlight the significant burden of Aspergillus-related chronic lung diseases in routine respiratory care.
- Research suggests that fungal balls (aspergillomas) are complex microbial ecosystems rather than simple collections of fungal growth.
- New diagnostic approaches using proteomics, DNA methylation and sequencing continue to show promise.
- Several studies explore improved diagnosis and treatment of aspergillosis in transplant recipients and other highly vulnerable patients.
Contents
- Tuberculosis Survivors and Aspergillosis Risk
- New UK Data on Aspergillus-Related Lung Disease
- Understanding Fungal Balls
- New Diagnostic Technologies
- Influenza-Associated Pulmonary Aspergillosis
- Transplantation and Immunotherapy Research
- What Does This Mean for Patients?
- References
Tuberculosis Survivors Face a Much Higher Risk of Pulmonary Aspergillosis
One of the most important studies published this week examined the long-term risk of pulmonary aspergillosis among people who have previously had tuberculosis (TB).
Researchers analysed nationwide health data and found that pulmonary aspergillosis occurred almost ten times more frequently in TB survivors than in matched controls. The incidence was 0.89 cases per 1,000 person-years among TB survivors compared with 0.09 cases per 1,000 person-years in the control group.
After adjusting for other risk factors, individuals with a history of TB remained nearly seven times more likely to develop pulmonary aspergillosis.
This finding reinforces a growing body of evidence showing that chronic pulmonary aspergillosis (CPA) is an important long-term complication of tuberculosis. Residual lung cavities and structural lung damage may provide an environment in which Aspergillus can establish chronic infection.
- Zo S, Lee KN, Han K, et al. Risk of Pulmonary Aspergillosis in Tuberculosis Survivors: A Nationwide Population-based Study.
International Journal of Antimicrobial Agents. 2026.
Patients who have previously had tuberculosis and continue to experience symptoms such as chronic cough, breathlessness, fatigue, weight loss or coughing up blood should discuss the possibility of CPA with their healthcare team.
New UK Data Highlight the Burden of Aspergillus-Related Lung Disease
A 10-year retrospective study from Imperial College Healthcare NHS Trust provides valuable insight into the scale of Aspergillus-related lung disease seen within a large UK respiratory service.
The researchers identified:
- 334 patients with serological allergic bronchopulmonary aspergillosis (sABPA)
- 145 patients with allergic bronchopulmonary aspergillosis (ABPA)
- 74 patients with chronic pulmonary aspergillosis (CPA)
- 38 patients with simple aspergilloma
- 11 patients with CPA-ABPA overlap disease
These figures demonstrate that Aspergillus-related conditions are encountered across a broad range of respiratory clinics and are not confined to specialist fungal centres.
- Venkatesan T, Nagi N, Nwankwo L, et al. Describing the Burden and Characteristics of Aspergillus-related Chronic Lung Disease at Imperial College Healthcare Trust: a 10-year Retrospective Study.
BMJ Open Respiratory Research. 2026.
The study highlights the importance of awareness among respiratory specialists, general physicians and primary care clinicians. Early recognition remains one of the biggest challenges in Aspergillus-related lung disease.
Fungal Balls Are More Complex Than Previously Thought
A fascinating multi-omics study examined fungal balls (aspergillomas) removed from patients with chronic pulmonary aspergillosis.
Traditionally, aspergillomas have been viewed as relatively simple accumulations of fungal material within pre-existing lung cavities. However, this research paints a much more complex picture.
The investigators found evidence that aspergillomas function as resilient microbial ecosystems involving interactions between Aspergillus species and bacteria, including organisms such as Pseudomonas aeruginosa.
The fungal communities also showed metabolic adaptations that may help them survive within the challenging environment of the lung cavity.
These findings may help explain why some aspergillomas remain difficult to eradicate and why bacterial co-infections can sometimes influence symptoms and treatment outcomes.
New Diagnostic Technologies Continue to Advance
Two veterinary studies published this week demonstrate the rapid development of advanced fungal diagnostic technologies.
Proteomics in Falcons
Researchers studying aspergillosis in falcons used plasma proteomics to identify potential biomarkers that may allow earlier diagnosis of infection.
Current diagnostic approaches often detect disease only after significant progression. The identification of blood-based biomarkers could eventually improve earlier detection and monitoring.
- Vieu S, Lozano C, Azmanis P, et al. Falcon Plasma Proteomics to Improve Avian Aspergillosis Diagnosis.
Journal of Proteomics. 2026.
DNA Methylation and Nanopore Sequencing in Chickens
A second study used host cell-free DNA methylation combined with nanopore sequencing to diagnose Aspergillus fumigatus infection in chickens with high accuracy.
Although these studies involve birds, they reflect wider trends in fungal diagnostics, where researchers are increasingly exploring:
- Proteomics
- Cell-free DNA analysis
- Next-generation sequencing
- Machine learning approaches
- Biomarker-based diagnostics
Future human diagnostics may rely less on culture-based testing and more on sophisticated molecular techniques that can identify disease earlier and more accurately.
Influenza and Aspergillosis: Understanding the Immune Response
A review published in Trends in Microbiology explores the mechanisms underlying influenza-associated pulmonary aspergillosis (IAPA).
Over the past decade, clinicians have recognised that severe influenza can predispose some patients to invasive Aspergillus infection.
The review discusses how viral infection can disrupt the delicate balance of immune responses in the lungs, creating conditions that allow Aspergillus to invade tissue.
The authors describe this balance as an inflammatory "rheostat" that regulates protection against infection while avoiding excessive tissue damage.
- Charrier Le Blan M, Biquand E, Briard B. Critical Role of the Inflammatory Rheostat in Influenza-associated Pulmonary Aspergillosis.
Trends in Microbiology. 2026.
While primarily relevant to critically ill hospitalised patients, the work improves our understanding of how viral infections and fungal infections interact.
Transplantation and Immunotherapy Research
Several studies this week focused on patients with severe immune suppression and organ transplantation.
Improved Diagnosis After Lung Transplantation
The GALACTBAS study suggests that galactomannan testing of tracheobronchial aspirates may improve detection of Aspergillus infection in lung transplant recipients.
The findings support the idea that some transplant-associated Aspergillus infections begin within the bronchial tree and may not always be detected early using traditional bronchoalveolar lavage (BAL) samples.
- Monforte A, Martín-Gómez MT, Berastegui C, et al. Diagnostic Value of Galactomannan in Tracheobronchial Aspirate for Aspergillus Infection in Lung Transplant Recipients.
Journal of Clinical Microbiology. 2026.
Kidney Transplant Patients
A prospective multicentre study found that invasive aspergillosis remained one of the most serious fungal complications after kidney transplantation, with mortality exceeding 40%.
Emerging Immunotherapies
Another review evaluated growing evidence supporting the use of immune-enhancing treatments such as:
- Interferon-gamma (IFN-γ)
- Anti-programmed death-1 (anti-PD-1) therapies
These approaches aim to strengthen antifungal immunity alongside standard antifungal treatment in selected patients with severe invasive mould infections.
Although still considered specialist therapies, interest in immunomodulation continues to grow.
What Does This Mean for Patients?
Several themes emerge from this week's publications:
- Previous tuberculosis remains one of the most important risk factors for chronic pulmonary aspergillosis.
- Aspergillus-related lung diseases continue to be under-recognised outside specialist centres.
- Fungal balls are biologically complex and involve interactions between fungi, bacteria and the lung environment.
- Diagnostic technology is advancing rapidly, particularly in biomarker and sequencing-based approaches.
- Research into immune-based treatments continues to expand alongside antifungal drug development.
Although many of these studies are early-stage or aimed primarily at researchers and specialists, together they show a field that is continuing to improve our understanding of how Aspergillus causes disease and how it might be diagnosed and treated more effectively in the future.
When to Seek Medical Advice
Patients with known lung disease should seek medical advice if they experience:
- Persistent or worsening breathlessness
- New or worsening cough
- Unexplained weight loss
- Fatigue that is worsening over time
- Coughing up blood (haemoptysis)
- New chest pain
- Persistent fever or night sweats
Individuals who have previously had tuberculosis should be particularly aware that chronic pulmonary aspergillosis can develop months or years after apparent recovery from TB.
References
- Zo S, Lee KN, Han K, et al. Risk of Pulmonary Aspergillosis in Tuberculosis Survivors: A Nationwide Population-based Study.
International Journal of Antimicrobial Agents. 2026. - Venkatesan T, Nagi N, Nwankwo L, et al. Describing the Burden and Characteristics of Aspergillus-related Chronic Lung Disease at Imperial College Healthcare Trust: a 10-year Retrospective Study.
BMJ Open Respiratory Research. 2026. - Liu C, Ribeiro MM, Yang J, et al. Multi-omics Profiling of Fungal Balls in Chronic Pulmonary Aspergillosis Patients Reveals Microbiome Dynamics and Metabolic Adaptations.
mBio. 2026. - Vieu S, Lozano C, Azmanis P, et al. Falcon Plasma Proteomics to Improve Avian Aspergillosis Diagnosis.
Journal of Proteomics. 2026. - Drag MH, Hvilsom C, Poulsen LL, et al. MethylSense: High Accuracy Machine Learning-Based Diagnostics for Aspergillus fumigatus Infection in Chickens Using Host Cell-free DNA Methylation and Nanopore Sequencing.
Journal of Clinical Microbiology. 2026. - Charrier Le Blan M, Biquand E, Briard B. Critical Role of the Inflammatory Rheostat in Influenza-associated Pulmonary Aspergillosis.
Trends in Microbiology. 2026. - Monforte A, Martín-Gómez MT, Berastegui C, et al. Diagnostic Value of Galactomannan in Tracheobronchial Aspirate for Aspergillus Infection in Lung Transplant Recipients.
Journal of Clinical Microbiology. 2026. - Serris A, Guihot A, Joffre J, et al. Emerging Evidence for Anti-PD-1 and IFN-γ as Adjunctive Immunotherapy in Invasive Mold Infections.
mBio. 2026.
Author: Graham Atherton, National Aspergillosis Centre (NAC)
Clinical Review: National Aspergillosis Centre Clinical Team
Last Reviewed: 15 June 2026
For Patient Education Only: This article is intended for educational purposes and should not replace professional medical advice.
The Hidden Job Nobody Talks About: Living with Chronic Illness
For many people, the hardest part of chronic illness is not always the symptoms. It is the constant work of managing them.
Key Points
- Chronic illness often creates a significant hidden workload.
- Patients manage medications, appointments, prescriptions, side effects, monitoring and healthcare administration.
- Fatigue and brain fog can make this workload even harder.
- Organisation helps, but organisation itself requires effort.
- Technology, pharmacists, medication reviews, family support and patient communities can help reduce the burden.
- Nobody should feel they have failed because they occasionally forget something.
Contents
- The Work Nobody Sees
- The Constant Background Process
- The Hidden Impact of Fatigue
- Grieving the Loss of Simplicity
- The Expert Nobody Wanted to Become
- Building an External Brain
- When Organisation Itself Needs Help
- Practical Ways to Reduce the Mental Load
- The Annual Medication MOT
- You Do Not Have to Carry It All Alone
- Final Thoughts
The Work Nobody Sees
When people think about chronic illness, they usually think about symptoms.
Breathlessness.
Pain.
Fatigue.
Cough.
Hospital appointments.
Medication.
These are certainly part of the picture.
But many patients would argue that another challenge receives far less attention.
The work.
Not paid work.
The hidden work of being a patient.
For many people, living with a chronic illness means becoming the organiser, administrator, coordinator and decision-maker for an ongoing healthcare programme.
There are prescriptions to order.
Appointments to attend.
Letters to understand.
Blood tests to arrange.
Side effects to monitor.
Questions to remember.
Symptoms to interpret.
Forms to complete.
Information to absorb.
And unlike most jobs, there are no weekends off.
Many patients are not only managing an illness. They are managing an entire healthcare programme.
The Constant Background Process
One patient recently described chronic illness as being like a computer running a programme permanently in the background.
Even on good days, the process never completely switches off.
Questions quietly run through the mind:
- Do I have enough medication?
- When is my next appointment?
- Should I order my prescription?
- Is this symptom normal?
- Is this a side effect?
- Have I forgotten something important?
Most healthy people can devote their attention entirely to daily life.
Many patients are simultaneously running this constant background process.
That process consumes energy.
It consumes concentration.
And over time it can become exhausting.
The work of being ill can sometimes feel almost as exhausting as the illness itself.
The Hidden Impact of Fatigue
Fatigue affects much more than physical energy.
It can affect:
- Memory.
- Concentration.
- Planning.
- Organisation.
- Decision-making.
This creates a difficult cycle.
The more tired someone becomes, the harder it is to stay organised.
The harder it is to stay organised, the easier it becomes to miss a prescription, forget an appointment or overlook an important detail.
That can create stress.
Stress itself is tiring.
Many patients eventually discover that they are not simply carrying the burden of their illness.
They are carrying the burden of managing the illness.
This is not weakness.
It is a normal human response to a sustained workload.
Grieving the Loss of Simplicity
Many people are not only grieving the loss of health.
They are grieving the loss of simplicity.
Remember when you could:
- Go away for the weekend without checking medication supplies?
- Accept invitations without calculating energy levels?
- Spend a day outdoors without thinking about medication side effects?
- Plan months ahead without wondering how you might feel?
Spontaneity often gives way to planning.
Simple decisions become calculations.
Many people find themselves missing the ease and simplicity they once took for granted.
That feeling is entirely understandable.
The Expert Nobody Wanted to Become
One of the remarkable things about people living with chronic illness is how much they learn.
Over time, patients often become experts in:
- Medications.
- Blood tests.
- Side effects.
- Hospital systems.
- Insurance.
- Benefits.
- Referral pathways.
Most never intended to acquire this knowledge.
They learned because circumstances required it.
As one patient put it:
"I never applied for the job, but somehow I became the project manager for my illness."
Many readers will recognise that immediately.
A person with aspergillosis may spend five minutes taking medication.
They may spend an hour thinking about medication.
The burden is often not the tablet itself.
The burden is remembering the tablet, remembering to reorder the tablet, remembering what it interacts with, remembering the blood test, remembering the side effects and remembering what to do if something changes.
Building an External Brain
One lesson many patients learn is that memory alone is not enough.
This is especially true when fatigue, pain, poor sleep or brain fog are present.
Successful long-term management often depends on creating systems that do some of the remembering for us.
Examples include:
- Paper diaries.
- Calendars.
- Whiteboards.
- Medication reminder apps.
- Smartphone reminders.
- Alexa or Siri reminders.
- Weekly pill organisers.
- Shared family calendars.
One patient described this as creating an "external brain".
The exact system matters less than the principle behind it.
The aim is not to remember everything. The aim is to build systems that do some of the remembering for you.
Technology Can Help
Smart speakers such as Amazon Alexa and voice assistants such as Apple Siri can act as simple reminder systems.
They can be used for:
- Medication reminders.
- Prescription reminders.
- Appointment reminders.
- Weekly health checks.
- Shopping lists.
- Clinic preparation.
For example:
"Alexa, remind me every Sunday evening to check my medication supplies."
Or:
"Hey Siri, remind me every first Monday of the month to order my repeat prescriptions."
For many patients these systems reduce stress and make it less likely that important tasks will be forgotten.
When Organisation Itself Needs Help
People are often told to "stay organised".
It is good advice.
But it overlooks something important.
Organisation itself requires effort.
Creating reminders.
Maintaining calendars.
Sorting medication.
Reading letters.
Booking appointments.
Ordering prescriptions.
All of these tasks require energy.
For someone already dealing with fatigue, breathlessness, pain or brain fog, even staying organised can sometimes feel overwhelming.
This is why support matters.
Support is not always about physical assistance.
Sometimes it is about sharing the responsibility of remembering.
A partner who reminds you about an appointment.
A family member who collects a prescription.
A friend who helps complete a form.
A pharmacist who helps simplify medication schedules.
These small acts can remove a surprising amount of pressure.
Organisation helps. But sometimes organisation needs help too.
Practical Ways to Reduce the Mental Load
Many patients find it helpful to:
- Schedule a weekly "health admin" session.
- Use a diary, whiteboard or calendar.
- Set medication reminders.
- Use a weekly pill organiser.
- Ask about pharmacy reminder services.
- Consider medication packaging systems.
- Share calendars with family members.
- Keep a running list of questions for clinic appointments.
The goal is not perfection.
The goal is to make life easier.
The Annual Medication MOT
Cars receive regular servicing.
Computers receive updates.
Financial plans are reviewed.
Yet many people take the same collection of medications for years without anyone stepping back and looking at the whole picture.
A structured medication review or polypharmacy review can help answer questions such as:
- Do I still need all these medicines?
- Could any side effects be contributing to symptoms?
- Are there interactions?
- Can the schedule be simplified?
- Is every medication still serving a clear purpose?
Sometimes the most useful prescription is not a new medication.
It is a review of the medications already being taken.
Sometimes the most useful prescription is not a new medication, but a review of the medications already being taken.
You Do Not Have to Carry It All Alone
Many of us value independence.
That is understandable.
However, there is a difference between independence and carrying every burden alone.
Help may come from:
- Pharmacists.
- Occupational therapists.
- Family.
- Friends.
- Carers.
- Charities such as Age UK.
- Patient support groups.
Often the most valuable support is not somebody doing something for us.
It is somebody helping us remember.
A second pair of eyes.
A second memory.
A second person asking:
"Have you got everything you need for next week?"
Final Thoughts
Living with a chronic illness is often described in terms of symptoms, test results and treatments.
But behind every clinic letter is a person carrying a mental checklist that never completely disappears.
The medications.
The appointments.
The prescriptions.
The side effects.
The blood tests.
The questions.
The worries.
The constant balancing act.
If you sometimes feel tired not only from your illness, but from the work of managing it, that feeling is understandable.
It may simply be a reflection of how much you are carrying.
No patient should feel they have failed because they forgot something, ran out of medication, missed a reminder or needed support.
Managing chronic illness is complex.
Nobody does it perfectly.
The aim is not perfection.
The aim is to build enough support, systems and kindness around ourselves that daily life becomes a little easier to manage.
The goal is not to prove that you can manage everything alone.
The goal is to build enough support around yourself that life becomes easier, safer and more enjoyable.
Author: National Aspergillosis Centre Patient Support Team
Last reviewed: June 2026
Medical disclaimer: This article provides general information and support. It should not replace advice from your own doctor, pharmacist, nurse or specialist team.
Useful sources and further reading
-
Suggested Internal Links
National Aspergillosis Centre Patient Support
https://aspergillosis.org/patients/Living with Aspergillosis
https://aspergillosis.org/living-with-aspergillosis/Chronic Pulmonary Aspergillosis (CPA)
https://aspergillosis.org/chronic-pulmonary-aspergillosis/Allergic Bronchopulmonary Aspergillosis (ABPA)
https://aspergillosis.org/allergic-bronchopulmonary-aspergillosis-abpa/Aspergillus Bronchitis
https://aspergillosis.org/aspergillus-bronchitis/Understanding Fatigue in Chronic Illness
Medication Information Hub
https://aspergillosis.org/antifungal-drugs/Voriconazole Information
https://aspergillosis.org/voriconazole/Itraconazole Information
https://aspergillosis.org/itraconazole/Posaconazole Information
https://aspergillosis.org/posaconazole/Isavuconazole Information
https://aspergillosis.org/isavuconazole/Adrenal Insufficiency and Steroid Information
National Aspergillosis Centre Online Support Meetings
https://aspergillosis.org/patient-meetings/The Aspergillosis Trust
https://aspergillosistrust.org/
Suggested External Links
Age UK
https://www.ageuk.org.uk/Carers UK
https://www.carersuk.org/NHS Structured Medication Reviews
https://www.england.nhs.uk/primary-care/pharmacy/smr/NHS Repeat Prescriptions
https://www.nhs.uk/nhs-services/prescriptions/
More Than a Referral Centre: How the National Aspergillosis Centre Supports Patients and Healthcare Professionals Across the UK
Combining specialist clinical care, diagnostics, multidisciplinary expertise, patient support, education and research to improve outcomes for people living with Chronic Pulmonary Aspergillosis.
The National Aspergillosis Centre (NAC) was established by NHS England to provide highly specialised care for people living with Chronic Pulmonary Aspergillosis (CPA), a serious fungal lung disease that can develop in patients with pre-existing respiratory conditions.
Over the last sixteen years the service has evolved into much more than a referral clinic. Today, NAC combines specialist clinical care, advanced diagnostics, multidisciplinary expertise, patient support, education and research, working alongside local healthcare teams throughout the UK.
Many clinicians are familiar with NAC as a specialist referral service. However, fewer may be aware of the breadth of support available through the centre, including specialist multidisciplinary team discussions, diagnostic expertise, physiotherapy, nursing support, pharmacy services, patient education programmes and nationally recognised fungal diagnostics.
This article provides an overview of how NAC supports both patients and healthcare professionals in the diagnosis and management of Chronic Pulmonary Aspergillosis.
"The National Aspergillosis Centre exists not only to care for patients with Chronic Pulmonary Aspergillosis, but also to support healthcare professionals throughout the UK in diagnosing and managing this complex condition."
Contents
- Why specialist support matters
- What does NAC do?
- Working with local teams
- Benefits for patients
- Benefits for healthcare professionals
- Patient support and education
- Research, education and innovation
- Why awareness still matters
- Further resources
- Working together
Why specialist support matters
Chronic Pulmonary Aspergillosis (CPA) is a serious fungal lung disease that can develop in people with pre-existing respiratory conditions including bronchiectasis, Chronic Obstructive Pulmonary Disease (COPD), previous tuberculosis, sarcoidosis and other structural lung diseases.
Patients may present with chronic cough, breathlessness, fatigue, weight loss, recurrent chest infections or haemoptysis. These symptoms frequently overlap with more common respiratory conditions, making diagnosis challenging.
CPA remains a relatively uncommon disease and many clinicians may encounter only a small number of cases during their careers. As a result, specialist support can be valuable when diagnosis is uncertain, investigations are difficult to interpret or treatment becomes complex.
The National Aspergillosis Centre was established to provide that support.
What does the National Aspergillosis Centre do?
NAC is commissioned by NHS England to provide highly specialised care for patients with Chronic Pulmonary Aspergillosis.
The service supports patients through:
- Specialist assessment and diagnosis
- Multidisciplinary review of complex cases
- Long-term disease monitoring
- Antifungal treatment planning and optimisation
- Therapeutic drug monitoring
- Assessment and management of antifungal resistance
- Management of drug interactions and adverse effects
- Specialist physiotherapy support
- Specialist nursing support
- Access to clinical research and trials
Every new CPA diagnosis is reviewed within a specialist multidisciplinary team, helping to ensure a consistent and evidence-based approach to diagnosis and management.
NAC in 2023–24
- 209 referrals assessed for aspergillosis
- 101 new confirmed CPA diagnoses
- 311 patients under active specialist follow-up
- 71 external cases discussed through the National MDT
- 56 remote advice and guidance consultations
Working with local teams
One of the most common misconceptions about referral is that patients must transfer all of their care to Manchester.
In reality, NAC operates primarily through a shared-care model.
Wherever possible, investigations, imaging, monitoring and routine care are organised locally, with NAC providing specialist input and treatment recommendations. This approach allows patients to benefit from national expertise while remaining close to home.
The service also supports healthcare professionals through remote advice, specialist consultation and participation in the National Multidisciplinary Team (MDT) meeting.
For many clinicians, discussing a case through the MDT can help clarify diagnosis, identify additional investigations and support treatment decisions before or alongside formal referral.
Benefits for patients
Patients referred to NAC gain access to one of the world's largest specialist CPA services.
Benefits include:
- Specialist review by clinicians with extensive experience in fungal lung disease
- Diagnostic clarification and confirmation
- Optimisation of antifungal therapy
- Management of treatment-related complications
- Access to specialist physiotherapy and nursing support
- Educational resources and self-management support
- Opportunities to participate in research
For many patients, specialist review provides reassurance, a clearer understanding of their condition and confidence in their treatment plan.
Benefits for healthcare professionals
The National Aspergillosis Centre exists not only to support patients, but also to support healthcare professionals.
Referral or specialist discussion may be particularly useful when:
- The diagnosis remains uncertain
- Radiological findings are difficult to interpret
- Patients are not responding as expected
- Antifungal toxicity develops
- Resistance is suspected
- A specialist second opinion would be valuable
Clinicians also gain access to expertise in therapeutic drug monitoring, antifungal stewardship, complex fungal diagnostics and long-term disease management.
Each referral creates opportunities for shared learning, helping local teams build experience and confidence in recognising and managing aspergillosis.
Patient support and education
One of the most distinctive features of the National Aspergillosis Centre is the support available beyond routine clinical care.
Many patients referred to NAC have experienced a long and sometimes frustrating journey to diagnosis. Symptoms may have been present for months or years before Chronic Pulmonary Aspergillosis is recognised.
Following diagnosis, patients are often faced with an unfamiliar condition and may encounter alarming information online that relates to very different forms of aspergillosis. It is therefore common for patients and families to feel anxious, isolated and uncertain about what the future may hold.
For this reason, patient support forms an important part of the NAC service.
Through the Community, Awareness, Research, Education and Support (CARES) programme, patients have access to:
- Regular patient support meetings
- Educational webinars and presentations
- Health and wellbeing sessions
- Patient newsletters
- Online information resources
- The Aspergillosis Patients and Carers website
- Peer support opportunities
One of the most common comments from newly diagnosed patients is the relief of discovering that they are not facing the condition alone. Meeting others living with aspergillosis and having access to trusted information can make a significant difference to confidence, understanding and long-term self-management.
"For many patients, finding the CARES programme is the moment they realise they are no longer facing aspergillosis on their own."
By combining specialist clinical care with education, support and community, NAC aims to help patients and families feel informed, supported and empowered throughout their journey.
Research, education and innovation
The National Aspergillosis Centre works closely with the Mycology Reference Centre Manchester (MRCM), one of Europe's leading specialist fungal diagnostic laboratories.
Together, NAC and MRCM contribute to:
- Clinical trials of new antifungal therapies
- Development of new diagnostic techniques
- Antifungal resistance surveillance
- National and international clinical guidelines
- Professional education and training
- Patient-centred research
The partnership has been recognised internationally through European Confederation of Medical Mycology (ECMM) Diamond Centre of Excellence status.
This close integration of clinical care, diagnostics, education and research helps ensure that patients benefit from the latest developments in fungal disease management.
Why awareness still matters
Chronic Pulmonary Aspergillosis remains an under-recognised disease worldwide.
Many patients present with symptoms that overlap with more common respiratory conditions such as COPD, bronchiectasis or previous tuberculosis. As a result, diagnosis can sometimes be delayed or missed.
This is not because clinicians are failing. CPA is an uncommon disease that can closely resemble more familiar respiratory conditions.
The role of NAC is therefore not simply to provide specialist treatment, but also to support earlier recognition of CPA through education, diagnostic support and collaborative working with healthcare professionals throughout the UK.
By raising awareness and improving access to specialist expertise, we hope to help more patients receive timely diagnosis, appropriate treatment and long-term support.
Further resources
- Aspergillosis Patients & Carers Website
- Chronic Pulmonary Aspergillosis Information Hub
- Patient Support Resources
- World Aspergillosis Day Resources
- Mycology Reference Centre Manchester
Working together
The National Aspergillosis Centre was established to ensure that patients with Chronic Pulmonary Aspergillosis have access to specialist expertise wherever they live.
Through shared-care working, multidisciplinary collaboration, specialist diagnostics, patient support, education and research, NAC continues to work alongside healthcare professionals throughout the UK to improve outcomes for people living with fungal lung disease.
Whether through referral, multidisciplinary discussion, specialist advice or educational resources, our aim remains the same: helping clinicians diagnose and manage aspergillosis with confidence while ensuring patients receive the support they need.
NAC is more than a referral centre. It is a national resource for patients, clinicians and healthcare services working together to improve the diagnosis and management of Chronic Pulmonary Aspergillosis.