Breathe journal June 2019 – ‘Living well with a Chronic Respiratory Disease’

The current issue of the European Respiratory Society’s journal, Breathe, focuses on living well with a chronic respiratory disease, and includes an article from an ABPA patient. Links to this patient voice article, and other pieces which may be of interest to aspergillosis patients are highlighted below.

Introduction: Living well with a chronic respiratory disease

Chief Editor, Claudia Dobler, introduces this issue in a short editorial. This covers a number of the burdens that lung disease patients can face, and the various ways in which they can achieve well-being and adjust to their circumstances in the face of chronic illness.

Living with allergic bronchopulmonary aspergillosis

Mike Chapman shares his experiences of living with ABPA and other respiratory problems. Many aspergillosis patients will identify with his experience of a lengthy and difficult journey to diagnosis, and trying to remain positive, despite debilitating health conditions.

Music and dance in chronic lung disease

This article covers the growing interest in using music and dance as part of a holistic approach to managing chronic lung disease. Several recent studies have focused on the benefits that music and dance have on the physical, mental and social health of those with chronic lung disease; this piece goes over some of this research, and the key gaps that are missing.

The role of cognitive behavioural therapy in living well with COPD

Anxiety and depression are common in people with chronic obstructive pulmonary disease and, as well as being major problems themselves, can interact with and worsen physical symptoms. This article again focuses on the holistic treatment of the patient, and suggests how we can incorporate CBT into routine care for those with COPD.

Where are the gaps in education in the field of rare lung disease? Perspectives from the ERN-LUNG educational programme survey

ERN-LUNG (the respiratory-focused European reference network) recently sent a survey out to healthcare professionals and patients to find out the gaps in rare lung disease education in Europe. From a patient’s perspective, a large majority thought that there was a need for patient education at a European level, but only just over a 3rd were aware of existing resources. 95% thought that patients had a role to play in the education of professionals. Read the article to see the key conclusions from the survey.

Click here to read the full journal

Aspergillus – Pseudomonas interactions; a match made in heaven or hell?

In the last years clinicians and researchers have realised that the interactions between microorganisms in polymicrobial infections (when a single patient is colonised/infected with two or more pathogens) are relevant for the progression of the disease. Contacts between pathogens can affect their fitness (how well they can grow inside us) and also impact on the response of our immune system. However, the research into this novel and extremely complex area is still in its infancy and we need to gain much more information before being able to understand what is going on in each specific condition. It is suspected that in some interactions the microorganisms may compete with each other, which is usually good for us. However, in other types of interactions the pathogens may help each other, which is of course detrimental for the patients. In the case of Aspergillus – Pseudomonas interaction it is still not completely clear which is taking place, a positive or a negative interaction.

Pseudomonas (mainly the species Pseudomonas aeruginosa) is a common bacterial pathogen and Aspergillus (mainly the species Aspergillus fumigatus) is the most common fungal pathogen of the human respiratory tract. Both organisms are able to grow in the lungs of immunosuppressed individuals and also of patients with certain underlying diseases, such as bronchiectasis, chronic obstructive pulmonary disease (COPD), hospital acquired pneumonia and cystic fibrosis. Since the awareness of the importance of polymicrobial infections is quite recent, there are not many reports of the incidence of co-infection with these two pathogens yet. One of the few, from the end of 2018, reported a prevalence of co-infection in cystic fibrosis patients of 15.8% (1). That means that almost sixteen percent of all cystic fibrosis patients may be co-infected with both Pseudomonas and Aspergillus… This is of course not trivial!

 Several studies carried out in various laboratories around the world would suggest that the interaction between Aspergillus and Pseudomonas is of competitive nature. That would indicate that they weaken each other during co-infection, which could mean good news for patients. However, there are also results, including some clinical evidence, that suggest the opposite, the pathogens could be helping each other in the human lungs. What seems clear is that having both pathogens is not good for the patients (2). Therefore, we need to understand how these microbes interact during co-infection to be able to decide which course of action is best, should we treat against both or only one? Which one first, or both at the same time?

To address these questions my research group, in the Manchester Fungal Infection Group, is trying to understand the specific interactions that take place between Aspergillus fumigatus and Pseudomonas aeruginosa under conditions that are similar to co-infection of the human lung.

We want to discover which interactions are the important ones. This will help us understand what is going on during co-infection and we can then use this knowledge to improve the management and treatment of patients.

Dr Jorge Amich | MRC Career Development Fellow

Manchester Fungal Infection Group (MFIG)

1. Zhao J, Cheng W, He X, Liu Y.2018. The co-colonization prevalence of Pseudomonas aeruginosa and Aspergillus fumigatus in cystic fibrosis: A systematic review and meta-analysis. Microb Pathog 125:122-128.

2. Reece E, Segurado R, Jackson A, McClean S, Renwick J, Greally P.2017. Co-colonisation with Aspergillus fumigatus and Pseudomonas aeruginosa is associated with poorer health in cystic fibrosis patients: an Irish registry analysis. BMC Pulm Med 17:70.

Is patient-to-patient transmission of Aspergillus fumigatus in CF patients possible?

A new study from the Netherlands has challenged the widely held opinion that airborne transmission of Aspergillus fumigatus between patients with cystic fibrosis (CF) does not occur.

Chronic Pulmonary Aspergillosis (CPA) is a chronic condition affecting patients with structural lung damage such as that caused by CF. It is generally accepted that patients become colonised by A. fumigatus following the inhalation of spores from the environment.

» Read more

Posaconazole works better than itraconazole and voriconazole against ABPA amongst Cystic Fibrosis patients

A recently published research paper suggests that Posaconazole works better than itraconazole and voriconazole against
allergic bronchopulmonary aspergillosis (ABPA) in patients with Cystic Fibrosis.

ABPA patients tend to have a hypersensitive response to Aspergillus species which results in inflammation, airway destruction and bronchiectasis. Cystic fibrosis (CF) patients are at risk of ABPA which then speeds up lung function decline. The current ‘gold standard’ treatment is prednisolone to reduce inflammation. Azoles have been used effectively as steroid alternatives but have various side effects and tolerance issues.

In the newly published paper the authors wanted to know if posaconazole, which is known to be less toxic and better absorbed than other azoles, was more effective at treating ABPA.

They analysed data from 596 CF patients, and reviewed the specific Aspergillus IgE levels and azole levels in blood samples. 32 patients were identified and included in the analysis. 11 had itraconazole alone, 12 had two different azoles and 9 received all three azoles. In total, 30 received itraconazole, 13 received voriconazole, 18 received posaconazole.

The authors found IgE levels to be significantly reduced when posaconazole was used, but not the other azoles, suggesting that monitoring posaconazole levels and altering the dose given to the patient to attain greater serum levels of IgE gives improved blood test results in ABPA patients.

Want to know more? Read the paper here!

Yeast that live in the human gut can trigger the immune system to cause inflammation in the lung, especially in patients with ABPA.

The yeast Candida albicans lives in the gut as a commensal organism, usually without issue. C. albicans causes the body to produce a particular kind of immune cell, called Th17 sensitive cells, that stop the Candida from causing infections. A new research paper out this month shows that the Th17 cells that react to Candida in the gut also react to Aspergillus in the lung by a process called ‘cross reactivity’.

Cross reactivity was shown to increase the levels of Aspergillus reactive Th17 cells in the blood of patients with Cystic Fibrosis, COPD and asthma, especially during ABPA. This indicates that there is a direct link between the normal, protective Th17 responses against Candida in the gut, and harmful inflammation by Aspergillus in the lung.

In other words, problems in your lungs might be made worse by the normal immune response to Candida in your gut. This knowledge could affect the way we treat flare ups in future. For example, we already know that using antibiotics can increase the growth of Candida in the gut. This new information raises the possibility that increased Candida in the gut could cause increased lung inflammation or a ‘flare up’ of symptoms in patients with Aspergillosis, but further work would be needed to confirm this.

Read the paper here

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