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

by GAtherton

⚠️ Warning Signs for Possible Aspergillosis in Primary Care

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

🟠 1. Asthma Not Responding to Guidelines-Based Treatment

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

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

  • Persistent cough or breathlessness between attacks

  • Thick or brown mucus plugs coughed up

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

🟠 2. Recurrent Chest Infections

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

  • Sputum samples that repeatedly show Aspergillus or colonising fungi

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

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

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

  • Especially if imaging shows lung abnormalities or patient is immunocompromised

  • May indicate CPA, not just asthma

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

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

  • Especially in patients with:

    • Bronchiectasis

    • COPD/emphysema

    • Old TB

    • Sarcoidosis

  • These conditions increase risk of CPA or colonisation becoming invasive

🟠 5. High Total IgE or Eosinophils

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

  • Blood eosinophils persistently >0.5 (especially off steroids)

  • Aspergillus-specific IgE or IgG positive

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

🟠 6. Radiology That Doesn’t Match the Diagnosis

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

    • HRCT shows bronchiectasis with mucus plugging

    • X-rays don’t improve despite treatment

    • Old TB scar now shows a cavity

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

🧭 What Should GPs and Nurses Do Next?

✅ Request:

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

  • Sputum for fungal culture if available

  • CXR or HRCT if not done recently

✅ Refer:

  • Respiratory specialist or Advice & Guidance

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

📋 Clinical Triggers for Flagging Aspergillosis

Trigger Possible Condition
Uncontrolled asthma + high IgE + mucus ABPA
Chronic cough + weight loss + cavity on CT CPA
Asthma + sensitisation to fungi + frequent steroids SAFS

by GAtherton

Waiting for Microbiological results after bronchoscopy or sputum?

Here’s a detailed overview of culture times for respiratory samples, including sputum, bronchoalveolar lavage (BAL), bronchial washings, and tissue biopsies. The times can vary slightly depending on the lab's protocols, but the ranges below are generally reliable.

🦠 Bacterial Cultures

Organism Type Culture Time Notes
Common respiratory bacteria 1–3 days Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis — fast growers.
Gram-negative bacilli 2–4 days Pseudomonas, Klebsiella, E. coli — often from hospital-acquired infections.
Anaerobic bacteria 5–7 days Require special culture conditions; longer if from lung abscess.
Atypical bacteria (e.g., Legionella) 5–7 days or longer Special media (e.g., BCYE); PCR is faster.
Nocardia 7–14 days (up to 21) Slow-growing, weakly acid-fast; resembles TB.

🌿 Fungal Cultures

Fungus Type Culture Time Notes
Aspergillus species 5–14 days (held up to 6 weeks) Colonies may appear within 5–10 days; full ID and sensitivity takes longer.
Candida species 1–3 days Grows quickly, but needs correlation with clinical signs (often coloniser).
Cryptococcus neoformans 3–7 days Faster than most moulds; may require specific media.
Dimorphic fungi (e.g., Histoplasma) 2–6 weeks Very slow-growing; incubation up to 6 weeks needed.
Zygomycetes/Mucorales 2–5 days Grow rapidly but fragile; easily missed if lab isn't alerted.

🧫 Mycobacterial Cultures

Mycobacteria Type Culture Time Notes
Mycobacterium tuberculosis 2–8 weeks Liquid cultures (e.g., MGIT) reduce time to ~10–21 days, but solid media held longer.
NTM (Non-tuberculous mycobacteria) 2–8 weeks (some longer) M. avium, M. kansasii, M. abscessus, etc.; slow or rapid growers.

🧪 Other Tests on Respiratory Samples (Non-culture)

Test Time Use
Gram stain / KOH prep Minutes to 1 day Rapid preliminary information.
Fungal PCR (e.g., Aspergillus) 1–3 days Can be used on BAL, biopsy; fast but not always standard.
Galactomannan (BAL) 1–3 days Indicates Aspergillus antigen; useful in early detection.
Cytology/Histopathology 3–7 days Can reveal fungi, TB, malignancy.

🔁 Summary: Longest-held Cultures

Held Up to Organism
6–8 weeks Mycobacteria (TB, NTM), dimorphic fungi (Histoplasma, Blastomyces)
3–6 weeks Moulds (Aspergillus, Scedosporium, Fusarium)
2–3 weeks Nocardia, anaerobes

If you're awaiting results after a bronchoscopy, most bacterial and yeast results return within the first 3–5 days, whereas fungal or TB/mycobacterial cultures may take weeks — especially if slow-growing pathogens are suspected.

by GAtherton