🫁 Mucus Plugging in Aspergillosis: What It Is, Why It Happens, and What It Means

For patients with ABPA, CPA, Aspergillus bronchitis, or asthma

🔍 What Is a Mucus Plug?

A mucus plug is a thick clump of sticky mucus that becomes trapped in your lungs. It can block airways, cause coughing, and make breathing more difficult. In people with aspergillosis, this is common — but the type, location, and cause of the mucus can vary.

🧪 What Causes Mucus Plugging?

Your lungs naturally make mucus to protect against germs and irritants. But in fungal or allergic lung disease, this mucus may:

  • Be produced in excess

  • Become too thick or sticky

  • Get trapped due to airway damage

Aspergillosis-related causes include:

  • ABPA (Allergic Bronchopulmonary Aspergillosis) – inflammation causes thick, sticky mucus

  • Aspergillus bronchitis – fungus lives in mucus, producing biofilms

  • CPA (Chronic Pulmonary Aspergillosis) – may lead to mucus due to structural damage

  • Bronchiectasis – airways are widened and can no longer clear mucus properly

🧬 Are All Mucus Plugs the Same?

No. Mucus plugs vary in colour, texture, cause, and treatment. Here's how they differ:

Type of Plug What You Might See What It Could Mean Common in...
Sticky, stringy Clear/yellow, like glue Allergic inflammation ABPA, asthma
Rubbery or solid Brown, rubbery, “slug-like” Allergic + fungal mix ABPA, Aspergillus bronchitis
Green or smelly Thick, foul-smelling Infection (bacteria) Bronchiectasis
Foamy or frothy Clear/white, bubbly Non-infectious irritation COPD, asthma
Black or speckled May contain fungal specks Fungal growth CPA, fungal bronchitis

🖼️ What Do Mucus Plugs Look Like on a CT Scan?

Below are real examples of CT scan findings showing mucus plugging in different forms of aspergillosis and related conditions.

🧷 1. Finger-in-glove sign (ABPA)

Mucus in large airways appears like fingers inside a glove. This is common in allergic fungal airway disease.

➡ Seen in: ABPA, bronchiectasis with fungal colonisation
📍 Note: Branching tubular opacities filled with mucus.

🌿 2. Tree-in-bud pattern

Small airway blockage — plugs in the tiniest branches of the lungs. Common in infection, inflammation, and Aspergillus bronchitis.

➡ Seen in: Aspergillus bronchitis, asthma, CPA with superinfection
📍 Note: Tiny dots and lines in a tree-like shape.

🧱 3. Lung collapse (atelectasis) from plug

A large mucus plug can block a main airway, causing collapse of part of the lung.

➡ Seen in: Severe ABPA, CPA, patients with weakened cough reflex
📍 Note: Whiteout of part of lung where plug is blocking airflow.

📸 Example CT Findings

 

1. Bronchiectasis + mucus plug
Area in the left lower lung shows dilated bronchi filled with mucus—classic for bronchiectasis with mucoid impaction

2. Extensive bronchiectasis with plugs
Widespread thick-walled airway dilatation accompanied by mucus plugs (black arrows) and consolidation (black arrowheads)

3. Luminal plugging in small airways
Subtle luminal opacities in peripheral bronchi—the “tree‑in‑bud” pattern common in asthma, COPD, and infections.

4. Atelectasis (part of the lung has collapsed or isn’t fully inflating) due to mucus plugging
Consolidation and small airway blockage leading to lung collapse, highlighted by arrows in the upper lobe.

💡 Clinical Takeaways

Feature What it indicates
Mucoid impaction Large airway fungal/allergic plugs (e.g., ABPA) or bronchiectasis
Tree‑in‑bud Small-airway infection/inflammation (e.g., TB, PCD, asthma)
Atelectasis Complete blockage, leading to collapse and consolidation
Persistent luminal plugs Associated with worse airflow obstruction and symptoms in COPD/asthma

✅ Next Steps / Applications

  • These CT examples are valuable for educational use—they illustrate the different patterns seen in mucus plugging across disease types.

  • Radiologists often use these signs to help diagnose and tailor management (infection, allergy, structural lung disease).

  • If your patients or students need simplified visuals, these scans paired with annotations (e.g., arrows, labels) can make great teaching tools.

🧠 What Does It Feel Like?

People often say:

“It felt like something was stuck and wouldn’t come out.”
“I finally coughed up a rubbery strand — like glue.”
“Once it cleared, I could breathe better instantly.”

🧼 How Are Mucus Plugs Treated?

Treatment depends on the underlying cause:

✅ Medications

  • Steroids – reduce inflammation in ABPA and asthma

  • Antifungals – lower fungal load (e.g., itraconazole, posaconazole)

  • Mucolytics – thin mucus (e.g., carbocisteine, hypertonic saline)

  • Antibiotics – treat bacterial infections

✅ Airway Clearance Techniques

  • Respiratory physio – helps you learn how to shift mucus

  • Devices – flutter valve, PEP mask, Acapella

  • Inhaled/nebulised therapy – opens airways and loosens plugs

⚠️ Always speak to your clinical team before starting a new technique.

🧪 Can Coughing Up a Plug Help Diagnosis?

Yes! If you cough up a rubbery, large, or unusual plug, it can be:

  • Tested for fungus, bacteria, or allergy cells (eosinophils)

  • Sent for culture to detect Aspergillus

  • Helpful in guiding or confirming diagnosis of ABPA or Aspergillus bronchitis

👣 Key Points for Aspergillosis Patients

Question Answer
Is mucus plugging common? Yes, especially in ABPA, CPA, and bronchiectasis
Are all mucus plugs the same? No – they vary in size, shape, colour, and cause
What should I do if I cough one up? Tell your doctor – it may be useful to test
Can it be seen on scans? Yes – CT can show where plugs are and how severe
Can it be treated? Yes – treatments include steroids, antifungals, mucolytics, and physio

by GAtherton

Patient Guide: Understanding Aspergillus-Related Chronic Pulmonary Disease

Based on new international guidance (2024)

What is Aspergillus and Why Is It Important?

Aspergillus is a common type of fungus found in the environment. Most people breathe it in every day without any problem. However, if you have a lung condition or a weakened immune system, Aspergillus can cause serious problems. It can:

  • Trigger allergic reactions in the lungs
  • Infect damaged lung tissue
  • Worsen symptoms like coughing, wheezing, or breathlessness

Until recently, doctors treated each type of aspergillus-related lung disease as a separate condition. But new guidance recognises that many patients may have more than one form or sit on a spectrum.

What Conditions Are Included?

The term "aspergillus-related chronic pulmonary disease" covers a range of conditions:

Condition What it means
ABPA (Allergic Bronchopulmonary Aspergillosis) An allergic reaction to Aspergillus, usually in asthma or cystic fibrosis patients
CPA (Chronic Pulmonary Aspergillosis) A slow-developing fungal infection, often in people with pre-existing lung damage
Aspergillus bronchitis A fungal infection in the airways, often in people with bronchiectasis
Overlap syndromes Some people show features of more than one of the above

What Are the Symptoms?

Symptoms can vary, but common signs include:

  • Persistent cough (sometimes with mucus or blood)
  • Wheezing or breathlessness
  • Fatigue and low energy
  • Weight loss or loss of appetite
  • Repeated chest infections

If you experience these symptoms and have an underlying lung condition, it’s important to ask whether Aspergillus might be involved.

How Is It Diagnosed?

Doctors now use a combination of tests to get a clearer picture:

  • Chest CT scan – to look for signs of lung damage or fungal balls
  • Sputum samples – to check for the presence of Aspergillus
  • Blood tests – to detect allergic antibodies (IgE), immune responses (IgG), or fungal antigens
  • Bronchoscopy (sometimes) – to collect samples directly from the lungs

These tests help doctors decide whether it’s an allergic reaction, an infection, or both.

How Is It Treated?

Treatment depends on your symptoms and test results. The aim is to:

  • Reduce inflammation
  • Clear fungal infection
  • Prevent further lung damage

Common treatment options include:

Treatment Purpose
Steroids (e.g. prednisolone) Reduce allergic inflammation (especially in ABPA)
Antifungal drugs (e.g. itraconazole, voriconazole) Treat fungal infection and reduce fungal burden
Biologic therapies (e.g. omalizumab, dupilumab) Used in difficult-to-treat allergic cases
Nebulised antibiotics If other infections (like Pseudomonas) are also present
Surgery (rarely) To remove fungal balls or damaged tissue in severe CPA

What Has Changed in the 2024 Guidance?

  • Doctors are now encouraged to look for overlapping features, not just one diagnosis.
  • More emphasis is placed on early detection and preventing lung decline.
  • Guidelines promote the use of multidisciplinary teams (MDTs) for complex cases.
  • Newer treatments, including biologics, are being recommended more often.
  • Patients with symptoms but unclear diagnoses should be re-evaluated regularly.

What Can You Do as a Patient?

  • Know your diagnosis – Ask your team whether your current label still fits your symptoms
  • Track your symptoms – Keep a log of cough, breathlessness, fatigue, and infections
  • Ask about specialist referral – For example, to a National Aspergillosis Centre
  • Stay informed – Visit aspergillosis.org for up-to-date guidance
  • Take medications as prescribed and report any side effects promptly

Support and Information

  • Patient support groups can help you connect with others
  • Pulmonary rehabilitation and breathing therapy can improve quality of life
  • Annual reviews and regular scans can help spot problems early

For more information, leaflets, and help getting the right care, visit: aspergillosis.org

You don’t have to manage this alone.

by GAtherton

🫁 ABPA Treatment: Why Are Steroids First, Even if They Can Increase Fungal Growth?

If you've been diagnosed with Allergic Bronchopulmonary Aspergillosis (ABPA), you may have heard that treatment often starts with oral steroids like prednisolone. But ABPA is triggered by a reaction to the Aspergillus fungus — so why use a treatment that might actually let that fungus grow more?

It’s a great question. This guide explains why steroids are still often the first step, what other treatments are available, and when they might be used.

🌿 What Is ABPA?

ABPA is not an infection — it’s an allergic immune reaction in the lungs to the fungus Aspergillus fumigatus. This overreaction causes:

  • Lung inflammation

  • Mucus plugging

  • Breathlessness and wheezing

  • Possible long-term lung damage (e.g., bronchiectasis)

People with asthma or cystic fibrosis are more likely to develop ABPA.

💊 Why Are Steroids Usually the First Treatment?

🔥 The key problem in ABPA is inflammation, not the fungus itself.

Steroids like prednisolone are often used first because they:

  • Act quickly to calm the allergic immune reaction

  • Reduce inflammation and mucus

  • Help relieve symptoms fast (wheezing, tight chest, breathlessness)

  • Prevent long-term damage if started early

Even though steroids may allow some fungal growth, their fast action against inflammation is often more important — especially in flare-ups.

🍄 What About Antifungal Treatments?

Antifungals like itraconazole or posaconazole reduce the amount of Aspergillus in the lungs. This helps to:

  • Reduce allergic triggers

  • Prevent future flare-ups

  • Lower the need for steroids

However, antifungals:

  • Take weeks to work

  • Don’t control inflammation well on their own during a flare

  • Can have side effects and interact with other medications

➡️ That’s why they are often used after steroids, or alongside them — especially in people who flare up often or need steroids long term.

🧬 What About Biologics?

Biologic therapies like:

  • Omalizumab (anti-IgE)

  • Dupilumab (blocks IL-4 and IL-13)

  • Mepolizumab (anti-IL-5)

…are used to help regulate the immune system in patients who:

  • Can’t tolerate steroids

  • Have frequent relapses

  • Need ongoing treatment despite antifungals

Biologics can help:

  • Reduce steroid use

  • Lower flare frequency

  • Improve asthma control

But they’re not yet approved as first-line treatments and are generally reserved for more complex or persistent cases.

✅ What Happens If My Symptoms Are Mild?

Good question. In mild ABPA (e.g. stable breathing, low IgE, no major lung damage), specialists may:

  • Monitor closely before starting any treatment

  • Try antifungals alone, especially if steroid use is risky

However, regular follow-up is essential to make sure inflammation doesn’t silently worsen.

🔄 Typical ABPA Treatment Steps

Stage Treatment
First flare or moderate symptoms Steroids (short course) ± antifungals
Steroid side effects or long-term use Add antifungals
Recurrent or steroid-dependent ABPA Add or switch to biologics
Mild symptoms and stable lungs Possibly antifungals first (specialist decision)

🧘 Staying Well with ABPA

  • Follow your treatment plan closely

  • Keep lungs clear with mucus clearance techniques

  • Avoid damp, mouldy environments

  • Keep up with regular check-ups and lung tests

  • Let your team know if symptoms return

🗨️ In Summary

Steroids are still first-line because they work fast to stop inflammation.
Antifungals and biologics are important longer-term options that help reduce fungal triggers and flare-ups — and may reduce or even replace steroids over time.

Every ABPA patient is different, and your care should be tailored to you.

by GAtherton

🫁 Understanding ABPA, Bronchiectasis & Lung Cavities

A Patient’s Guide to What Happens in the Lungs – and What You Can Do About It

🌿 What is ABPA?

Allergic Bronchopulmonary Aspergillosis (ABPA) is a condition where the lungs react strongly to a common fungus called Aspergillus. This overreaction causes inflammation in the airways, making it harder to clear mucus and increasing the risk of flare-ups.

Many people with asthma or cystic fibrosis are more likely to develop ABPA, but it can affect others too.

🌀 What Happens to the Lungs?

Over time, repeated inflammation and mucus build-up can affect the structure of the airways. Here’s what can happen:

1. Bronchiectasis

  • The airways (bronchi) become widened and thickened.

  • This makes it harder to clear mucus, which can lead to more infections.

  • In ABPA, this usually affects the central parts of the lungs.

🔸 Bronchiectasis is not the same as a lung cavity. It’s a change in the shape of the airways, not a hole in the lung.

2. Lung Cavities (Less Common)

  • These are air-filled spaces that form when a small area of lung tissue is damaged or infected.

  • Cavities are less common in ABPA but can happen after repeated inflammation or infection.

  • They may look worrying on a scan, but often they are just monitored and don’t cause major issues unless they become infected.

🩺 What About Lung Function?

ABPA and bronchiectasis can affect lung function, especially if not caught early.

  • Spirometry tests may show lower results if the airways are blocked or inflamed.

  • Some people improve after treatment; others may see a gradual decline.

  • Most patients still breathe well at rest, and many stay active with proper care.

🌬️ Will Cavities Leak Air?

This is a common worry. The answer is: usually not.

  • Most cavities in ABPA are not at risk of bursting or leaking.

  • Sudden breathlessness or chest pain should always be checked, but leaks (pneumothorax) are rare in ABPA.

📉 Does Everyone Get Cavities?

Not at all.

  • Around 50–90% of ABPA patients get some bronchiectasis.

  • Only a minority go on to develop true cavities.

  • Early treatment and regular check-ups help reduce the risk of further lung changes.

🧪 What About Oxygen Levels?

Many people with ABPA — even with bronchiectasis — still have normal oxygen levels (SpO₂):

  • Most rest between 95–98%

  • During a flare or infection, it might dip a little

  • If oxygen drops below 92%, your team may check more closely

🧘 What Can I Do to Stay Well?

  • 🩺 Stick to your treatment plan – antifungals, inhalers, or steroids if prescribed

  • 💨 Clear mucus regularly – ask about airway clearance techniques

  • 🧼 Avoid damp, mouldy environments

  • 🍎 Stay active and eat well

  • 📆 Attend check-ups and lung function tests

  • 🚭 Avoid smoking or vaping (these can worsen damage)

💬 A Final Word

Having ABPA and some lung changes doesn’t mean life has to stop. Many people continue to live active, fulfilling lives. Even with bronchiectasis or small cavities, the focus is on prevention, staying stable, and getting support when needed.

by GAtherton

📘 Managing IgE Levels in ABPA: What Happens After Treatment?

If you have ABPA (Allergic Bronchopulmonary Aspergillosis), you’ve likely been told your IgE levels are high. Many patients ask:

“Once my IgE goes down with treatment, how do I keep it down without staying on steroids or antifungals forever?”

This guide explains why IgE is important, how it’s treated, and what long-term steps you can take to stay well.

🧪 What is IgE and Why Is It High in ABPA?

IgE (Immunoglobulin E) is an antibody your immune system makes in response to allergens. In ABPA, your immune system overreacts to Aspergillus, a common fungus, causing inflammation in the lungs. This leads to:

  • High total IgE levels (often over 1,000–10,000 IU/mL)

  • Symptoms like coughing, wheezing, and mucus plugs

  • Lung changes on scans, if untreated

🎯 Treatment Goals

Treatment aims to:

  • Lower inflammation

  • Reduce the fungal burden

  • Bring IgE levels down (a marker that your inflammation is settling)

  • Prevent long-term lung damage

You might be treated with:

  • Oral steroids (e.g. prednisolone)

  • Antifungal tablets (e.g. itraconazole or voriconazole)

These medications help bring IgE levels down, sometimes dramatically. But they can’t usually be taken forever — long-term use may cause side effects.

🔄 After IgE Drops – What Next?

Even after successful treatment, ABPA can flare up again. So the key questions become:

How do we keep IgE low?
How do we prevent future flare-ups?

🧭 Long-Term Management Options

1. Close Monitoring

  • IgE is checked every 2–6 months

  • Doctors look for a doubling in IgE — this can mean a flare is starting

  • Regular chest scans and lung function tests are also used to spot changes early

2. Tapering Medication

  • Steroids are slowly reduced, not stopped suddenly

  • Your doctor will watch for any return of symptoms or rise in IgE

3. Biologic Treatments

Some newer medications can help long-term, especially if you:

  • Have frequent flare-ups

  • Can’t reduce steroids safely

  • Have asthma or eosinophilic inflammation

These include:

  • Omalizumab (anti-IgE antibody)

  • Mepolizumab / Benralizumab (target eosinophils)

  • Dupilumab (blocks part of the allergy pathway)

Biologics are usually injections given every 2–4 weeks, and can help reduce relapses and steroid need.

🏡 Lifestyle & Environmental Tips

Reducing your exposure to Aspergillus can help keep IgE from rising again.

🔹 Avoid:

  • Damp or moldy areas

  • Compost, rotting leaves, hay, or soil dust

  • Rooms with poor ventilation

🔹 Use:

  • Ventilate your home well (eg open windows/extractor fans)

  • A HEPA-filter air purifier at home

  • An FFP2/FFP3 mask when doing dusty activities (gardening, cleaning mold)

🥗 Eat for Immune Support:

  • Anti-inflammatory foods (vegetables, oily fish, berries)

  • Reduce sugar (high sugar may promote inflammation)

  • Stay well hydrated

  • Ask your doctor about vitamin D — it may help regulate immunity

📅 Follow-up Schedule (General examples, yours may differ)

Time Since Treatment What to Expect
1–3 months Blood tests (IgE, eosinophils), lung check
3–6 months Check for symptoms, possibly repeat IgE
6–12 months CT scan or lung function, if needed
After 1 year Stable patients may have annual reviews

Let your team know if any symptoms return — even if your last IgE result was stable.

🧠 Final Thoughts

  • You may always have “elevated” IgE compared to someone without ABPA — that’s okay. The goal is stability, not “zero IgE”.

  • Many patients live well with ABPA for years by learning to manage flare-ups early and avoiding fungal exposure.

  • Ask your clinic about your personal IgE pattern — some people flare with small changes; others don’t.

  • Support groups and educational resources (like aspergillosis.org) can help you stay informed and confident.

📩 Have questions for your team?

Bring these up at your next appointment:

  • Can I reduce my medication safely?

  • Could I benefit from a biologic?

  • How often should I check my IgE?

  • How can I reduce exposure at home?

by GAtherton

🏠 NICE Guidance on Damp and Mould (NG149) — Simple Summary

1. Health Risks

  • Damp and mould produce spores and irritants that can trigger or worsen respiratory and heart conditions, including asthma, bronchitis, and fungal infections, like aspergillosis Link

  • They can also affect skin, eyes, and mental wellbeing, especially in vulnerable people such as those with asthma, COPD, babies, pregnant women, and older adults .

2. When Health Issues Worsen

If you experience repeated cough, wheeze, or other breathing issues — and your home has damp or mould — health professionals are advised to:

  • Ask about your home conditions

  • Help you arrange a housing assessment by the council Link

3. Landlord and Council Responsibilities

Landlords and councils should:

  • Act quickly and sensitively when damp or mould is reported — medical proof is not required Link

  • Identify and fix the root cause (e.g., faulty guttering leading to mould) — not just clean it off Link.

  • Keep clear records, follow up after repairs, and inspect properties periodically to prevent recurrence Link

4. Tenant Health Priority

Homes with serious damp and mould are classed as Category 1 hazards under UK housing law, meaning they pose an immediate health risk. Councils must act — they can enforce repairs, impose notices, or carry out work themselves Link.

5. How You Can Use This with Your Council

  • Point to NICE NG149 guidance to emphasise that damp and mould are a legal and health priority.

  • Remind them that action must be urgent, especially for people with lung conditions.

  • Ask them to identify and fix the cause, not just scrub the mould — like ensuring guttering is repaired and mould-prone areas are treated and dried.

  • Ask for a follow-up inspection to confirm the problem is resolved.

📩 Suggested Wording to Share with Your Council

“According to NICE guidance (NG149), damp and mould in homes are considered serious health hazards — especially for people with lung conditions like aspergillosis. Councils and landlords must act quickly to fix the root cause, not just remove visible mould. These guidelines recognise that even without medical proof, urgent action is required to protect tenants’ health.”

by GAtherton

🏥 Can a GP Refer You Directly to the National Aspergillosis Centre (UK)?

❌ Unfortunately, no — not directly.

The NAC is a tertiary referral centre, meaning that:

  • Referrals must come from a hospital consultant (usually a respiratory or infectious diseases specialist)

  • The NAC cannot accept direct referrals from GPs or from patients themselves

This is due to NHS policy and service structure — not because they don’t want to help.

✅ What Your GP Can Do:

Even though they can’t refer you directly, your GP can advocate on your behalf and help move things forward by:

  1. Writing to your current hospital consultant to request:

    • A second opinion from NAC

    • Transfer of care or joint management with NAC

    • Review of your images, sputum results, and previous history

  2. If your current hospital won’t cooperate, your GP can:

    • Refer you to a different respiratory consultant (at another hospital if needed)

    • Ask that this new consultant considers NAC referral

  3. If your case involves rare, persistent, or poorly controlled lung disease with suspected Aspergillus involvement, the NAC is usually happy to review — but only after that consultant request is made.

📂 What to Send (via the consultant)

Your hospital team (at your GP’s request) should ideally send:

  • Latest CT scans and chest X-rays

  • Sputum culture results

  • Total and specific IgE / Aspergillus IgG

  • A clear clinical history summary

  • Any previous diagnosis letters or clinic notes

🗣️ If You’re Still Not Getting Help

If your current consultants won’t help and your GP is willing, you might also:

  • Ask your GP to refer you to a private respiratory specialist (for one appointment only) who may agree to refer you to NAC from there.

  • Or contact your local Patient Advice and Liaison Service (PALS) to escalate the block in access.

💬 Suggested Wording for Your GP:

“I’ve had long-standing respiratory symptoms with suspected Aspergillus involvement and limited progress under my current hospital team. I understand referral to the National Aspergillosis Centre requires a hospital consultant, but would you be willing to request that my current team (or an alternative respiratory consultant) considers this referral on my behalf?”

💡 Summary:

  • ❌ GPs cannot refer you directly to NAC

  • ✅ Your GP can request your hospital consultant do it — and advocate for you

  • 🛑 If you're being blocked, ask to be referred to another consultant who may be more open to referring to NAC

by GAtherton

🏥 Surgery in Patients with ABPA or CPA: Can It Worsen Symptoms, and Should It Proceed?

Patients with Aspergillus-related lung diseases, such as Allergic Bronchopulmonary Aspergillosis (ABPA) and Chronic Pulmonary Aspergillosis (CPA), sometimes report worsened symptoms after undergoing surgery under general anaesthetic. While this is a recognised clinical pattern, it does not mean surgery should be avoided. Instead, it requires preparation and close perioperative management to reduce risk.

🔍 Can Surgery Worsen Aspergillosis Symptoms?

Yes — and here's why:

✳️ 1. Airway Irritation from Intubation

  • Endotracheal tubes can irritate airways already inflamed by ABPA or structurally altered by CPA.

  • Mechanical ventilation can impair mucus clearance and exacerbate cough or infection.

✳️ 2. Postoperative Immunosuppression

  • Surgery temporarily suppresses immune function.

  • Perioperative corticosteroids or stress-induced immune suppression can permit fungal flare-ups or reactivation.

✳️ 3. Impaired Mucus Clearance

  • Pain, immobility, and sedation reduce the patient’s ability to cough and clear secretions.

  • In CPA or ABPA, this can lead to plugging, fungal regrowth, or secondary bacterial infection.

✳️ 4. Drug Interactions

  • Azole antifungals (e.g. itraconazole, posaconazole) interact with many anaesthetics, opioids, and steroids.

  • These interactions can alter drug levels, reduce antifungal efficacy, or increase toxicity risk.

✳️ 5. Stress and Inflammation

  • Surgical stress may worsen the inflammatory or allergic component of ABPA.

  • CPA-related cavities may bleed or become re-infected post-op.

✅ Should Surgery Still Go Ahead?

Yes — surgery can and often should proceed when it is medically indicated.

Delaying needed procedures (e.g. for cancer, fractures, or pain relief) can lead to worse outcomes than the potential risks related to aspergillosis.

🛡️ Recommended Precautions

🔷 Pre-Operative Planning

  • Ensure all care teams are aware of the diagnosis.

  • Review lung imaging, baseline oxygenation, and current antifungal/steroid regimens.

  • Arrange for pre-op airway clearance if sputum is a concern.

🔷 Antifungal Management

  • Continue antifungal therapy through the perioperative period.

  • Use IV formulations if oral administration isn’t possible.

  • Check for drug interactions with anaesthetic or post-op medications.

🔷 Steroid Cover (ABPA and CPA on steroids)

  • Patients on chronic steroids may need perioperative hydrocortisone supplementation (adrenal cover).

  • Apply “sick day rules” or use the patient’s adrenal insufficiency plan, if applicable.

🔷 Post-Op Monitoring

Watch for:

  • Worsening cough, breathlessness, or sputum

  • Fever or signs of secondary infection

  • Raised IgE (in ABPA) or haemoptysis (in CPA)

  • Any signs of antifungal failure or drug toxicity

⚠️ When Might Surgery Be Delayed?

Consider postponing non-urgent surgery if:

  • There is active haemoptysis

  • The patient has uncontrolled inflammation or fungal burden

  • A recent scan shows expanding cavities or new infiltrates

  • Antifungal resistance is suspected or not yet managed

💬 Key Message for Patients

“Having ABPA or CPA doesn’t mean you can’t have surgery — but we do need to take extra care around your airways, your antifungal treatment, and your recovery. With the right team and planning, we can safely support you through your procedure.”

by GAtherton

Adrenal Insufficiency in Aspergillosis: Important Risks for Patients and GPs

🫁 Who is at Risk?
People with aspergillosis — especially ABPA (Allergic Bronchopulmonary Aspergillosis) and CPA (Chronic Pulmonary Aspergillosis) — are often treated with:

  • Steroids (inhaled or oral, such as fluticasone or prednisolone)
  • Azole antifungal medications (like itraconazole, voriconazole, posaconazole)

Both of these can affect the adrenal glands, though azole antifungals only do so indirectly in combination with a steroid medication. When used together, or when steroids are used on their own for long periods of time at a high dose, they can significantly increase the risk of a serious condition called adrenal insufficiency (AI) — when the body can’t produce enough cortisol to respond to stress or illness.

💊 Why Azole Antifungals Make This Worse
Azoles (itraconazole, voriconazole, posaconazole) block liver enzymes (CYP3A4) that normally break down inhaled or oral steroids. As a result:

  • Even inhaled steroids (like fluticasone or budesonide) can build up in the body

This can lead to systemic steroid effects, including:

  • Adrenal suppression
  • Cushing’s-like symptoms (weight gain, moon face, skin thinning)
  • Higher risk of adrenal crisis if steroids are stopped too fast or during illness

This is especially well documented with fluticasone + itraconazole — a known high-risk combination.

🚨 What is Adrenal Insufficiency?
Adrenal insufficiency means your adrenal glands cannot produce enough cortisol, the hormone your body needs to:

  • Regulate blood pressure and sugar
  • Respond to infections and illness
  • Maintain energy, mood, and salt balance

Without cortisol, even a minor illness can become life-threatening — this is called an adrenal crisis.

🔍 Warning Signs of Adrenal Suppression

  • Fatigue and muscle weakness
  • Low mood or confusion
  • Weight loss or loss of appetite
  • Dizziness when standing (low blood pressure)
  • Nausea, abdominal pain
  • Skin changes (e.g. thin skin, stretch marks, bruising)
  • Cushingoid appearance (round face, fat on upper back)
  • During stress (infection, surgery, trauma), people may:
  • Vomit or collapse
  • Become drowsy or disoriented
  • Experience dangerously low blood pressure or blood sugar

🛡️ What GPs and Patients Should Do
For GPs:

  • Be alert to the interaction between inhaled corticosteroids and azoles
  • If a patient is using inhaled fluticasone or budesonide and starts azoles:
  • Consider switching to a non-CYP3A4-metabolised inhaler (e.g. beclometasone)
  • Monitor for signs of adrenal suppression or Cushing’s
  • If adrenal insufficiency is suspected:
  • Arrange morning cortisol testing
  • Consider Short Synacthen Test (SST)
  • Educate patients on sick day rules and ensure:
  • A steroid emergency card is provided
  • An adrenal crisis plan is in place
  • Emergency hydrocortisone is prescribed if needed

For Patients:

Tell your GP or specialist if you are on:

    • Azoles (like itraconazole, posaconazole)
    • Any form of steroids (inhaled, nasal, oral, injected)
  • Never stop steroids suddenly — they may need to be reduced slowly
  • Report symptoms like fatigue, nausea, or dizziness
  • Ask about a sick day plan — you may need to double your steroid dose during illness
  • If you become very unwell, tell emergency services you are at risk of adrenal crisis

💬 Summary
Adrenal insufficiency is a real and under-recognised risk in aspergillosis — especially when azole antifungals are used alongside inhaled or oral steroids. Patients and GPs should work together to prevent and manage this serious complication.

by GAtherton

⚠️ Summer 2025 Travel Warning: Fungal Lung Infections a Hidden Risk

Important information for UK travellers, GPs and patients with chronic lung conditions

As more UK residents prepare to travel this summer — whether for holidays, charity work, military duty, or visiting family abroad — it’s important to raise awareness of a growing health risk that is often overlooked: fungal lung infections.

These conditions can be serious, persistent, and easily mistaken for other illnesses — including long COVID, TB, or bacterial pneumonia.

🌍 Fungal Infections Can Be Acquired Abroad — and Not Just in the Tropics

Fungal spores live in soil, compost, dust, and decaying organic matter. In many parts of the world, especially dry or tropical climates, travellers can unknowingly inhale spores that can cause long-term lung disease — often weeks or months after returning to the UK.

🧳 Key Risk Regions and Infections

🇺🇸 Valley Fever (Coccidioidomycosis)

  • Endemic to the southwestern United States — including Arizona, California, Nevada, Texas, and New Mexico

  • Caused by inhaling Coccidioides spores from dry, dusty soil

  • Affects travellers, farm workers, and military personnel

  • Can cause chronic cough, fatigue, joint pain, and lung nodules

❗ UK patients with unexplained lung symptoms should be asked about travel to these areas — Valley Fever can mimic CPA or even lung cancer.

🌎 Other Endemic Fungal Risks for Travellers

Disease Region(s) Typical Exposure
Histoplasmosis Central/South America, Africa, Asia Caves, bird/bat droppings, demolition sites
Blastomycosis Central USA (Great Lakes, Mississippi) Soil, wood, riverside areas
Paracoccidioidomycosis Brazil, Colombia Rural farming dust
Talaromycosis SE Asia, Southern China, India Dusty environments (esp. in immunocompromised)
Sporotrichosis Latin America, Africa, Japan Plant thorns, soil, cat scratches
Cryptococcosis Worldwide Bird droppings, tree bark

🌾 UK Risks Still Apply at Home

Even without travel, UK residents can develop Aspergillus-related conditions (CPA, ABPA) through:

  • Gardening (esp. with compost)

  • Farming or stables

  • Building or renovation work

  • Damp housing

Drug-resistant Aspergillus fumigatus is also rising in the UK — partly due to the use of agricultural fungicides.

🩺 Advice for GPs and Respiratory Teams

Ask:

  • Have you travelled to dry, dusty regions or tropical countries this year?

  • Have you been exposed to soil, caves, animals, compost, or renovation dust?

  • Do you have underlying lung disease (e.g. asthma, COPD, bronchiectasis)?

Consider:

  • Fungal testing (Aspergillus IgG/IgE, fungal cultures)

  • CT imaging for persistent nodules or cavitations

  • Early referral to respiratory or infectious disease specialists

  • Contacting the National Aspergillosis Centre for persistent or complex cases

✅ What Travellers Can Do

  • Wear a dust mask when gardening, hiking, or working around soil

  • Avoid enclosed spaces with bird or bat droppings

  • Seek help if you return from travel and develop:

    • A cough that won’t go away

    • Fatigue, fever, or weight loss

    • Chest tightness or unexplained breathlessness

📌 Final Reminder

Fungal infections are not rare — they’re under-recognised.
This summer, think fungal if you or your patient return from travel with persistent lung symptoms. Early diagnosis can make all the difference.

by GAtherton