Aspergillus Tracheobronchitis (ATB) for Expert patients and non-Specialist Clinicians

Expert Information for Patients, GPs, and Specialist Nurses

🔎 What Is Aspergillus Tracheobronchitis?

Aspergillus tracheobronchitis (ATB) is a rare but serious form of airway-invasive aspergillosis that primarily affects the trachea and large bronchi, rather than the lung parenchyma. It occurs predominantly in immunocompromised patients and may present with obstructive airway symptoms or respiratory failure.

ATB can exist on a spectrum from superficial colonisation to ulcerative or pseudomembranous invasion of the bronchial wall.

🧬 Pathophysiology

• Inhaled Aspergillus spores adhere to and invade damaged airway mucosa.

• Occurs more commonly when local airway immunity is impaired (e.g. in transplant recipients or critical illness).

• May co-exist with invasive pulmonary aspergillosis (IPA) or appear in isolation.

👥 Who Is at Risk?

High-risk groups include:

• Lung transplant recipients

• Hematopoietic stem cell transplant patients

• Severe COPD or structural airway disease

• Patients with prolonged corticosteroid use

• Critically ill or mechanically ventilated patients

• COVID-19 or influenza patients (sometimes overlapping with CAPA/IAPA)

⚠️ Clinical Presentation

Symptoms depend on the degree of airway obstruction and depth of invasion:

• Cough (dry or productive)

• Worsening breathlessness

• Stridor or wheeze

• Hoarseness or vocal changes

• Fever unresponsive to antibiotics

• Haemoptysis (may be life-threatening)

• Airway obstruction or collapse in advanced cases

ATB may be mistaken for tracheobronchial malignancy, infection, or stenosis.

🧪 Diagnosis

Bronchoscopy is essential for diagnosis:

• Direct visualisation of:

  • Ulceration

  • Pseudomembranes

  • Plaques

  • Necrotic debris

• Biopsies may reveal fungal hyphae invading mucosa.

Microbiological Investigations:

• Culture and PCR for Aspergillus from BAL or brushings

• BAL galactomannan

• Serum galactomannan or β-D-glucan may be supportive

• CT chest may be normal or show airway thickening, bronchial wall invasion, or tree-in-bud opacities

💊 Treatment

Systemic Antifungals:

• Voriconazole is first-line

• Isavuconazole or liposomal amphotericin B if azole intolerant or resistant

Airway Management:

• Debridement or bronchoscopic removal of pseudomembranes in severe obstruction

• Airway stenting in refractory strictures

• Nebulised antifungals (e.g. amphotericin B) may be used as adjunct in selected cases

Prompt initiation of antifungal therapy is vital. Delays can lead to respiratory failure or death.

🧾 Monitoring

• Clinical response: breathlessness, cough, fever

• Repeat bronchoscopy in some cases

• CT imaging of airways

• Antifungal drug levels

• Liver and renal function

📚 More Information

• ATB is under-recognised, especially in non-neutropenic or critically ill patients.

• Should be considered in transplant recipients or ICU patients with persistent respiratory symptoms and negative bacterial cultures.

• Referral to respiratory, infectious diseases, and ICU teams is essential.

• Resources: aspergillosis.org ; BTS Statement on  aspergillosis

by GAtherton

Aspergillus Bronchitis for Expert Patients and non-Specialist Clinicians

Expert Information for Patients, GPs, and Specialist Nurses

🔎 What Is Aspergillus Bronchitis?

Aspergillus bronchitis is a chronic fungal infection of the airways by Aspergillus fumigatus (or rarely other Aspergillus species), seen in individuals with structural lung disease or impaired mucociliary clearance. Unlike ABPA, it is not allergic in origin and does not involve systemic invasion, but is characterised by persistent fungal colonisation with active infection.

🧬 Pathophysiology

• Chronic colonisation of the conducting airways by Aspergillus

• Local immune dysfunction (but not systemic immunosuppression)

• Low-grade inflammation and increased mucus production

• Often coexists with bronchiectasis, COPD, or CF

👥 Who Is at Risk?

Most commonly seen in patients with:

• Bronchiectasis (non-ABPA)

• Cystic fibrosis

• COPD or asthma with sputum production

• Post-viral or structural airway damage

• Chronic antibiotic or corticosteroid use

Not typically seen in severely immunocompromised hosts (in whom invasive aspergillosis is more likely).

⚠️ Common Symptoms

• Persistent productive cough

• Thick sputum often yellow or green

• Worsening breathlessness or wheeze

• Chronic sputum positivity for Aspergillus

• Mild fever or malaise (but often afebrile)

• Poor response to antibiotics alone

Symptoms may resemble chronic bacterial bronchitis or overlap with infective exacerbations of bronchiectasis.

🧪 Diagnosis

Diagnosis requires a combination of clinical and microbiological evidence, with exclusion of ABPA and CPA.

Diagnostic Features:

1. Chronic productive cough (>4 weeks)

2. Repeated isolation of Aspergillus from sputum or BAL

3. Elevated Aspergillus IgG (typically present)

4. Normal or mildly elevated total IgE (typically <1000 IU/mL)

5. Absence of cavitary lesions or ABPA features on CT

6. Response to antifungal treatment supports diagnosis

🛑 Exclude:

• ABPA (IgE >1000, eosinophilia, central bronchiectasis)

• CPA (cavities, weight loss, radiological progression)

💊 Treatment

First-Line:

• Oral antifungals (usually for 3–6 months)

  • Itraconazole (first choice)

  • Voriconazole or posaconazole (if resistant/intolerant)

• Monitor drug levels and LFTs

Adjuncts:

• Physiotherapy and airway clearance techniques

• Nebulised saline or mucolytics

• Treat co-infections (e.g. Pseudomonas) where relevant

In patients with CF, consider co-management with a specialist CF team.

🧾 Monitoring

• Sputum cultures to monitor persistence or clearance

• Aspergillus IgG levels

• Symptoms (sputum, breathlessness)

• Liver function and drug monitoring

• Periodic CT imaging if symptoms worsen or haemoptysis occurs

📚 More Information

• Aspergillus bronchitis is often underdiagnosed in patients with recurrent "non-resolving chest infections".

• Patients benefit from coordinated care between respiratory, microbiology, and infectious disease specialists.

• Referral to the National Aspergillosis Centre is appropriate for refractory or complex cases.

• Resources: aspergillosis.org, Review: Pulmonary Aspergillosis: Spectrum of Disease;

  Aspergillus bronchitis without significant immunocompromise

• BTS Statement on  aspergillosis

by GAtherton