⚠️ 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

🫁 Why Is CPA Called a Long-Term Condition — Not a Lifelong One?

Chronic Pulmonary Aspergillosis (CPA) is often described as a long-term condition, but people sometimes wonder why it isn’t called a “lifelong” disease — especially since many people need antifungal treatment and regular monitoring for years.

Here’s what we know:

🩺 CPA Affects Everyone Differently

CPA is a complex condition that includes several forms — some people have a single fungal ball (aspergilloma), while others have more widespread or progressive disease. For many, CPA needs long-term treatment, such as antifungal tablets, oxygen, physiotherapy, or hospital care.

But not everyone has the same experience:

  • Some people are stable for years

  • Some respond well to treatment and no longer need antifungals

  • Others may live with occasional flare-ups or long-term health problems

🔁 Why It’s Not Always Called Lifelong

CPA is called a “long-term condition” because:

  • It typically lasts at least a year, often longer

  • It may come and go in phases

  • It needs regular follow-up and may affect daily life

But not everyone will have it for the rest of their life — and that’s why we don’t use the word “lifelong” for everyone.

🔬 We Don’t Yet Know Who is Truly ‘Cured’

To say whether CPA is curable, we would need to:

  • Follow a large group of patients

  • For many decades

  • To see who stays well and never relapses

That kind of long-term research is still ongoing — so at the moment, doctors can’t say for sure when or if someone is permanently cured.

Some people stay well for years after stopping treatment — but it’s too early to know if the infection is truly gone, or just sleeping.

💬 What This Means for You

  • CPA is a condition that can be managed — sometimes very successfully

  • You might not need treatment forever — but regular check-ups help catch any changes early

  • Your team will work with you to find the right balance of treatment and independence

  • If you feel well, that's a good sign — but it's still important to keep an eye on things

📍In short: CPA is a serious, long-term condition, but it’s not always lifelong. We still have more to learn, and long-term studies are helping us understand it better every year.

by GAtherton

💊 How Medicines Are Approved — and What “Off-Label” Means

🔹 1. What Is “Licensed” or “Approved” Medication Use?

Before a medicine can be prescribed in the UK (or any country), it goes through a formal approval process:

Step What Happens
Clinical trials The medicine is tested for safety, effectiveness, and quality.
Regulatory review In the UK, the Medicines and Healthcare products Regulatory Agency (MHRA) or the European Medicines Agency (EMA) reviews trial data.
Marketing authorisation If approved, the medicine is “licensed” for specific conditions, doses, age groups, and methods of use.

🟢 A licensed use means the drug has been judged safe and effective for that specific use, based on strong clinical evidence.

🔹 2. What Is “Off-Label” Use?

Off-label use means a doctor prescribes a medicine in a way that is not covered by its official license.

This could include:

  • Using a medicine for a different condition

  • Giving it at a different dose or frequency

  • Using a different route (e.g. inhaled instead of injected)

  • Giving it to a different age group (e.g. in children)

This is legal, but it means the prescriber is using their clinical judgement outside the official licensing terms.

🔹 3. Why Might a Doctor Use a Medicine Off-Label?

Reason Example
There is no licensed treatment for a rare condition e.g. inhaled amphotericin B for CPA or ABPA
The licensed treatment doesn’t work or causes side effects e.g. switching antifungal drugs
New evidence supports another use, but the company hasn’t applied for a new licence e.g. old drugs used in new ways based on research
Medicines used in children or elderly often lack specific licensing data

🔹 4. Is Off-Label Use Safe?

It can be, but it requires:

  • Good clinical judgement

  • Use of the best available evidence

  • Often, discussion with a multidisciplinary team

  • Informed consent from the patient (especially important in high-risk cases)

The prescriber takes more responsibility, because the use hasn’t been formally approved by regulators.

🔹 5. Who Oversees This in the UK?

  • The MHRA licenses medicines.

  • The General Medical Council (GMC) and NHS allow doctors to prescribe off-label when it’s in the patient’s best interest.

  • NICE guidelines sometimes include off-label use if evidence supports it.

🔹 6. Real-World Example: Inhaled Amphotericin

  • Licensed: Amphotericin B is approved for injection to treat fungal infections.

  • Off-label: Nebulised (inhaled) use is not officially licensed, but it is used in some centres to treat or prevent fungal lung disease (e.g. CPA, ABPA) where evidence and specialist experience supports it.

🔹 Summary: Key Points

Term Meaning
Licensed use The use of a medicine that has been approved for a specific purpose by a regulator.
Off-label use Prescribing a medicine in a different way than officially licensed — legal, but used with clinical caution.
Who decides? Ultimately, the prescribing clinician, supported by evidence, guidance, and the needs of the individual patient.

by GAtherton

🧠 Why Some Medications Can't Be Prescribed by GPs

In the UK, the NHS uses a tiered prescribing system that sometimes prevents GPs from prescribing certain medications, even if those medicines are available elsewhere in the NHS.

Here’s a clear explanation of how and why this happens:

🔒 1. Shared Care or Specialist-Only Medications

Some medicines are designated as “specialist-only” or “shared care” treatments. This means:

  • GPs are not authorised to initiate them.

  • In some cases, they can continue a prescription once a specialist starts it — but only if a formal shared care agreement is in place.

Examples include:

  • Biologics for asthma, ABPA, or autoimmune disease

  • High-risk antifungals like voriconazole or posaconazole

  • Certain cancer, transplant, or hormone drugs

This system ensures that:

  • The medication is closely monitored by someone with specialist knowledge

  • Risks like interactions, side effects, and required blood tests are safely managed

📜 2. Local Prescribing Formularies

Each NHS Integrated Care Board (ICB) or local NHS Trust maintains a formulary — a list of medicines approved for use in that area.

  • If a medicine isn't on the local formulary, the GP may be unable to prescribe it, even if NICE (the National Institute for Health and Care Excellence) says it's effective.

  • These decisions are based on local budget priorities, agreements with hospitals, and clinical capacity.

💷 3. Cost Controls and Prior Approvals

Some medications are expensive or highly specialised, and require:

  • Prior approval by a funding panel

  • A hospital-based consultant to apply for and justify the treatment

GPs usually cannot access these approval pathways directly.

⚠️ 4. Liability and Risk

Even if a GP understands the condition, they may not have:

  • Access to monitoring protocols

  • Up-to-date knowledge of rare drug interactions or side effects

  • The ability to interpret complex blood results needed for safe prescribing

For legal and safety reasons, GPs must follow guidance from their local ICB or NHS England on what they can and can’t prescribe.

✅ What Patients Can Do

  • Ask the hospital team if the medication can be prescribed under shared care, and whether your GP has agreed to it.

  • Ask your GP to request guidance from the local medicines management team.

  • Request a hospital prescription if urgent — but note this often requires collection from hospital pharmacies.

by GAtherton

NHS:10 year plan

The NHS Long Term Plan, published in January 2019, outlines a comprehensive strategy to transform the NHS in England over the next decade. It aims to improve patient care, enhance efficiency, and ensure the sustainability of the health service. The plan focuses on several key areas: 

🏥 1. A New Service Model for the 21st Century

  • Integrated Care Systems (ICSs): Establishing ICSs across England to coordinate services and improve population health. 

  • Community-Based Care: Shifting focus from hospital-centric care to community and primary care, providing services closer to patients' homes.

  • Digital Access: Expanding digital services, including online consultations and access to health records, to enhance patient convenience.

🩺 2. Preventing Illness and Tackling Health Inequalities

  • Preventive Measures: Implementing programs to reduce smoking, obesity, and alcohol-related harm. 

  • Early Detection: Enhancing screening and early diagnosis for conditions like cancer and cardiovascular diseases.

  • Addressing Disparities: Focusing on reducing health inequalities across different communities.

🧠 3. Improving Mental Health Services

  • Increased Funding: Allocating additional resources to mental health services.

  • Access Expansion: Improving access to mental health support for children, adolescents, and adults.

  • Crisis Care: Developing comprehensive crisis care services available 24/7.

👶 4. Supporting Children and Maternity Services

  • Maternity Care: Enhancing continuity of care during pregnancy and childbirth.

  • Child Health: Improving services for children with complex needs and expanding immunisation programs.

🧬 5. Advancing Genomic and Personalised Medicine

  • Genomic Testing: Integrating genomic testing into routine care to personalise treatment plans.

  • Research and Innovation: Investing in research to develop new treatments and technologies.

💻 6. Embracing Digital Technology

  • Electronic Health Records: Ensuring all patient records are digitized and accessible across care settings.

  • Telehealth Services: Expanding virtual consultations and remote monitoring to increase access and efficiency.

👩‍⚕️ 7. Workforce Development

  • Staff Recruitment and Retention: Implementing strategies to attract and retain healthcare professionals.

  • Training and Education: Providing continuous professional development opportunities for NHS staff.

💷 8. Financial Sustainability

  • Efficient Resource Use: Reducing administrative costs and reinvesting savings into patient care.

  • Funding Allocation: Ensuring funds are directed towards areas with the greatest impact on health outcomes.

The NHS Long Term Plan represents a significant commitment to transforming healthcare delivery in England, focusing on prevention, personalisation, and integration to meet the evolving needs of the population.

For more detailed information, you can access the full plan here: NHS Long Term Plan.

by GAtherton

Your NHS

The structure of the NHS (National Health Service)—particularly in the UK context—helps promote community, integrity, moral values, and ethics in several ways. While the NHS is often under pressure, its core design remains rooted in collective responsibility, public service ethics, and social solidarity.

🧭 1. Foundational Principles Reflect Ethical Commitments

The NHS was founded in 1948 on three core principles:

  • It meets the needs of everyone

  • It is free at the point of delivery

  • It is based on clinical need, not ability to pay

These principles are inherently moral—they prioritise fairness, compassion, and equal dignity, reinforcing the value that health care is a public good, not a commodity.

🏘️ 2. Community-Centred Service Delivery

  • Local NHS trusts and Integrated Care Systems (ICSs) deliver care close to where people live. This local structure:

    • Encourages community engagement

    • Supports collaboration with charities, social care, and volunteers

    • Reflects local health needs and inequalities

This fosters a sense of shared ownership, where patients and clinicians work within and for their communities.

🩺 3. Professional Integrity and Ethical Training

  • NHS staff are bound by strict professional codes of conduct (e.g. GMC, NMC) promoting:

    • Honesty, accountability, respect, and patient autonomy

  • Ethical frameworks guide decision-making in:

    • Consent

    • End-of-life care

    • Resource prioritisation

Training and reflective practice help staff embed moral reasoning in everyday clinical work.

🤝 4. Public Service Ethos and Social Trust

Because NHS workers are public servants, not driven by profit, the service promotes:

  • A duty to care over personal gain

  • Greater transparency and scrutiny

  • Stronger patient trust

Polling consistently shows that the public views NHS staff as among the most trusted professions in the UK.

💷 5. Universal Funding Model

  • Funded largely through progressive taxation, the NHS embodies solidarity—the healthy contribute to the sick, the wealthy to the less well-off.

  • This builds a shared sense of mutual support, unlike systems that divide people by insurance status or income.

📣 6. Ethical Frameworks for Difficult Choices

When resources are limited (e.g., organ transplants, ICU beds), the NHS applies publicly debated ethical frameworks:

  • NICE decisions are based on cost-effectiveness and fairness

  • Pandemic response planning includes ethics boards and public input

This helps maintain moral legitimacy even in hard decisions.

🚨 Challenges and Reality Check

While the NHS structure supports ethics and community, underfunding, waiting lists, and workforce shortages sometimes strain these ideals. However, the institutional values remain intact, and many staff stay in the NHS because of these shared values.

🌱 In Summary

The NHS promotes community, integrity, and ethics through:

  • Universal access based on need

  • Local, community-led care

  • Public funding and service ethos

  • Professional ethical codes

  • Fair, transparent decision-making

It is not just a healthcare system—it’s a moral statement about what a society owes its people.

by GAtherton

🌿 Tezepelumab (Tezspire) and ABPA: What You Need to Know

If you’ve been living with ABPA and find your symptoms keep coming back despite steroids and antifungal treatment, your consultant may suggest a biologic (monoclonal antibody). One of the newer options being offered to some patients in the UK is Tezepelumab, brand name Tezspire.

💡 What is Tezepelumab?

Tezepelumab is a biologic injection that targets a molecule called TSLP (thymic stromal lymphopoietin). TSLP is an early trigger in the chain reaction that leads to inflammation in the lungs. By blocking it, Tezepelumab can calm multiple allergic and eosinophilic pathways, which makes it different from most other biologics that only block one type of inflammation.

✅ Who Might Be Offered Tezepelumab?

Tezepelumab is approved by NICE for use in the NHS in people aged 12+ with severe asthma, especially those who:

  • Are on high-dose inhaled steroids and still struggling

  • Have had 3+ asthma flare-ups in the last year, or

  • Need to take regular oral steroids

If you have both ABPA and severe asthma, you might be offered Tezepelumab—even though it isn’t specifically licensed for ABPA.

🔍 How Does It Compare to Other Biologics?

Here’s a quick comparison:

Biologic Name Target NHS Use Needs High IgE or Eosinophils?
Omalizumab IgE Severe allergic asthma ✅ Yes – High IgE needed
Mepolizumab IL-5 Eosinophilic asthma ✅ Yes – High eosinophils needed
Benralizumab IL-5 receptor Eosinophilic asthma ✅ Yes
Dupilumab IL-4/13 Allergic asthma ❌ No, but usually allergy-type
Tezepelumab TSLP (upstream) Severe asthma (NICE-approved) ❌ No – works across all types

🧠 Why this matters: If your IgE or eosinophil levels aren’t high, Tezepelumab may still work for you—even when other biologics aren't suitable.

💷 Is Tezepelumab Expensive?

Yes—but it's funded on the NHS for patients who meet NICE criteria.

  • List price: ~£1,265 per injection (monthly)

  • NHS pays less through a confidential discount agreement

  • It’s not necessarily cheaper than other biologics, but it offers wider eligibility and broad activity

⚖️ Is It Better Than Other Biologics?

It depends. Some patients respond well to older biologics like omalizumab or mepolizumab, especially if their ABPA overlaps with allergy or eosinophilic asthma. But Tezepelumab may be a better fit if:

  • You don’t qualify for the others (e.g. your IgE is too low)

  • You’ve tried other biologics and they didn’t help enough

  • Your ABPA overlaps with hard-to-control asthma

While Tezepelumab isn’t licensed specifically for ABPA, its upstream targeting may help reduce flare-ups in those with overlapping conditions.

💉 Side Effects

Most people tolerate Tezepelumab well. Possible side effects include:

  • Injection site reactions (redness, swelling)

  • Headache or sore throat

  • Allergic reaction (rare)

It's given by subcutaneous injection once a month, often at hospital initially, but home administration may be an option later on.

👩‍⚕️ What to Ask Your Consultant

  • Why are you recommending this biologic for me?

  • Will it help with both my ABPA and asthma?

  • How soon should I expect results?

  • Can I stop steroids if this works?

Keeping a symptom diary and reporting back is really useful to your team.

🧾 Summary

Question Tezepelumab (Tezspire) Answer
Licensed for ABPA? ❌ No, but used off-label when asthma overlaps
Approved for NHS use? ✅ Yes – via NICE for severe asthma
IgE or eosinophils needed? ❌ No
Dose/frequency Monthly injection
Broad anti-inflammatory effect? ✅ Yes – acts early in the pathway

Tezepelumab is opening new doors for people with ABPA and severe asthma who’ve struggled with flare-ups, steroid side effects, or biologics that didn’t work. It’s not for everyone, but it’s worth a conversation with your specialist.

by GAtherton

🧬 Biologic Treatments for ABPA (Allergic Bronchopulmonary Aspergillosis)

Many people with ABPA who continue to experience flare-ups despite steroids and antifungals are now being offered biological therapies—also known as monoclonal antibodies.

These treatments target specific parts of the immune system involved in allergic inflammation. They're often used when:

  • Steroids are needed frequently or at high doses

  • Antifungals alone aren’t enough

  • ABPA keeps recurring and affecting quality of life

💉 Biologics Currently Used in ABPA

The following biologics are being used in the UK, particularly in specialist centres and often in patients with ABPA plus severe asthma or eosinophilic disease:

Biologic Name Target Brand Name Notes
Omalizumab IgE Xolair Most commonly used; good for high IgE and allergic asthma
Mepolizumab IL-5 Nucala For eosinophilic inflammation; steroid-sparing
Benralizumab IL-5 receptor (IL-5Rα) Fasenra Rapidly reduces eosinophils; monthly or 8-weekly injection
Dupilumab IL-4 and IL-13 Dupixent Used in allergic-type asthma and some ABPA patients
Reslizumab IL-5 Cinqaero IV infusion; less commonly used in ABPA
Tezepelumab TSLP (upstream cytokine) Tezspire Newest option; blocks multiple inflammatory pathways; doesn’t require high IgE or eosinophils

👉 Note: No biologic is officially licensed specifically for ABPA, but many are used off-label in patients with overlapping severe asthma or allergic disease.

✅ What Do Patients Say?

Many people treated with biologics report:

  • Fewer flare-ups or “chest infections”

  • Less need for oral steroids

  • Clearer breathing, less coughing, and better energy

Not everyone responds, but many see significant improvement in control and quality of life.

⚠️ Side Effects

Biologics are generally well-tolerated. Possible side effects include:

  • Mild injection site reactions (redness, swelling)

  • Headaches or fatigue

  • Allergic reactions (rare)

They’re usually given every 2–8 weeks as an injection under the skin, sometimes in hospital at first and then possibly at home.

🩺 What to Ask Your Consultant

  • Why have you chosen this biologic for me?

  • Will it help my asthma as well as ABPA?

  • How soon will I know if it’s working?

  • Will I still need antifungals or steroids?

  • Are there any alternatives if this one doesn’t work?

📌 Summary

Key Point Biologics in ABPA
Used when Steroids aren’t enough or cause side effects
Most used Omalizumab, Mepolizumab, Tezepelumab
Goals Reduce flares, improve breathing, lower steroid use
Licensed for ABPA? ❌ No – but used off-label in many UK centres
NHS funding? ✅ Yes – when criteria for severe asthma are met

by GAtherton

Understanding Aspergillosis: A Guide for Expert Patients and Clinical Professionals

Aspergillosis is an umbrella term for a group of diseases caused by infection or hypersensitivity to fungi in the Aspergillus genus, most commonly Aspergillus fumigatus. The spectrum of disease ranges from benign colonisation to aggressive, life-threatening invasive infection, depending on the host’s immune status and pre-existing lung condition.

🔍 Main Forms of Aspergillosis

Type Description Typical Host
Allergic Bronchopulmonary Aspergillosis (ABPA) A hypersensitivity reaction to A. fumigatus in the airways, with airway inflammation and mucus plugging Asthma or cystic fibrosis patients
Chronic Pulmonary Aspergillosis (CPA) Long-term infection of damaged lung tissue; may form cavities, fibrosis, or fungal balls (aspergilloma) Patients with COPD, TB history, sarcoidosis, or bronchiectasis
Aspergilloma A fungal ball within a lung cavity, often seen in CPA Pre-existing lung cavity from TB or sarcoidosis
Invasive Aspergillosis (IA) Rapid tissue-invasive fungal infection, often bloodstream dissemination Immunocompromised hosts (neutropenia, transplant, high-dose steroids, haematological malignancy)
Sinopulmonary and Disseminated Aspergillosis Involvement of sinuses, CNS, bone, or multiple organs Usually in immunocompromised or advanced disease
Allergic Aspergillus Sinusitis (AAS) Similar to ABPA but in the sinuses Atopic individuals, often with nasal polyposis

👥 Who Is Vulnerable?

Risk varies by form:

1. ABPA

  • Adults or children with moderate-to-severe asthma

  • Patients with cystic fibrosis

2. CPA / Aspergilloma

  • Structural lung disease: TB scarring, COPD, sarcoidosis, bronchiectasis

  • Immune dysregulation: diabetes, corticosteroid use

3. Invasive Aspergillosis

  • Neutropenic patients (especially haematological malignancies)

  • Solid organ or stem cell transplant recipients

  • Chronic granulomatous disease

  • ICU patients (especially with influenza or COVID-19)

⚠️ Main Symptoms and Diagnostic Red Flags

Symptom Suggestive Of
Persistent cough, often productive ABPA or CPA
Wheeze, breathlessness, chest tightness ABPA
Haemoptysis (mild to severe) Aspergilloma, CPA, sometimes ABPA
Weight loss, fatigue, night sweats CPA or IA
Facial pain, nasal discharge Aspergillus sinusitis
Fever, hypoxia, sepsis signs Invasive aspergillosis

🧪 Diagnosis

📌 ABPA

  • Elevated total IgE (>1000 IU/mL)

  • Raised Aspergillus-specific IgE/IgG

  • Eosinophilia

  • Chest CT: central bronchiectasis, mucus impaction ("finger-in-glove")

  • Positive sputum culture or PCR for A. fumigatus

📌 CPA

  • Symptoms >3 months

  • Chest imaging: cavitary lesions, fungal ball, pleural thickening

  • Positive Aspergillus IgG

  • Repeated positive cultures/PCR from sputum or BAL

  • Exclusion of TB and other mimics

📌 Invasive Aspergillosis

  • Imaging: halo sign, air crescent sign on CT

  • Serum galactomannan, (1→3)-β-D-glucan, PCR

  • BAL galactomannan and culture

  • Tissue biopsy (definitive)

💊 Treatment Approaches

🟦 ABPA

  • Oral corticosteroids (mainstay)

  • Itraconazole or posaconazole to reduce fungal burden

  • Biologics (e.g. omalizumab, mepolizumab, benralizumab) in steroid-dependent or resistant cases

🟧 CPA

  • Long-term triazole antifungals (e.g. itraconazole, voriconazole, posaconazole)

  • Monitoring of serum drug levels, liver function

  • Surgical resection in selected cases (aspergilloma)

  • Inhaled amphotericin B in refractory cases

🟥 Invasive Aspergillosis

  • Voriconazole (first-line)

  • Liposomal amphotericin B (alternative)

  • Duration: typically 6–12 weeks

  • Manage immunosuppression, treat underlying disease

🧭 Monitoring and Follow-up

  • Serial imaging (CT or X-ray)

  • Aspergillus IgG/IgE titers

  • Liver function and antifungal serum levels

  • Patient-reported symptom scores and quality of life

📚 Further Information and Resources

  • National Aspergillosis Centre (NAC): aspergillosis.org,

  • UK Clinical Guidelines: BTS CPA Guidelines (2016), ERS ABPA position paper (2020)

  • Support Groups: NAC Patient Support Facebook Group, Aspergillosis Trust

  • Referral Pathway: Respiratory teams can refer to NAC via NHS e-Referral system or Advice & Guidance. NAC is a tertiary NHS service so referrals cannot be made by a GP.

by GAtherton

COVID-19 Associated Pulmonary Aspergillosis (CAPA) for Expert Patients and non-Specialist Clinicians

Expert Information for Patients, GPs, and Specialist Nurses

🔎 What Is CAPA?

CAPA is a form of invasive pulmonary aspergillosis (IPA) that develops in patients with severe COVID-19, particularly those in intensive care units (ICU) with acute respiratory distress syndrome (ARDS). It is an opportunistic fungal infection caused by Aspergillus fumigatus, occurring without traditional risk factors such as neutropenia.

CAPA is part of the broader group of IAPA (Influenza-Associated Pulmonary Aspergillosis) and VAPA (Viral-Associated Pulmonary Aspergillosis).

🧬 Pathophysiology

  • Severe viral pneumonia (COVID-19) damages the airway epithelium.

  • Inhaled Aspergillus spores invade damaged lung tissue.

  • Corticosteroids (e.g. dexamethasone), immunomodulators (e.g. tocilizumab), and prolonged ventilation increase susceptibility.

👥 Who Is at Risk?

Primarily affects patients with:

  • Severe COVID-19 pneumonia, especially those with:

    • ICU admission

    • Mechanical ventilation

    • ARDS

  • Corticosteroid therapy or IL-6 inhibitors (e.g. tocilizumab)

  • Underlying lung disease (COPD, asthma)

  • Diabetes mellitus

📍 CAPA may occur even in immunocompetent individuals due to local lung immune disruption.

⚠️ Clinical Features

Often non-specific and difficult to distinguish from worsening COVID-19:

  • Persistent or worsening respiratory failure

  • New pulmonary infiltrates on imaging

  • Fever despite antibacterial therapy

  • Haemoptysis or pleuritic chest pain (less common)

  • Increased oxygen or ventilatory support requirement

🧪 Diagnosis

CAPA is challenging to diagnose and relies on clinical suspicion, radiology, and mycological evidence.

Diagnostic Tools:

  • CT Chest:

    • Nodules, cavitations, halo sign (often non-specific in COVID)

  • Bronchoscopy with BAL:

    • Galactomannan (BAL GM ≥1.0 = probable CAPA)

    • Culture and PCR for Aspergillus

  • Serum Galactomannan or β-D-glucan:

    • May be positive but less sensitive than BAL

  • Histopathology (rarely obtained due to ICU setting)

Diagnostic Categories (ECMM/ISHAM 2020):

  • Proven: histology showing fungal invasion

  • Probable: radiology + mycology from BAL

  • Possible: suggestive clinical picture + limited microbiology

💊 Treatment

First-Line:

  • Voriconazole (IV or oral)

  • Isavuconazole (alternative with fewer side effects)

  • Consider liposomal amphotericin B if azole resistance or intolerance

Additional Considerations:

  • Therapeutic drug monitoring (TDM) required for voriconazole

  • Duration: typically 6–12 weeks depending on response and immune status

  • Minimise immunosuppression where possible

Empirical antifungal therapy may be started in ICU when suspicion is high, even before full confirmation.

🧾 Monitoring

  • Respiratory function

  • Repeat imaging to assess progression or resolution

  • Serum galactomannan

  • Liver function, renal function, and drug levels

  • Screen for drug interactions (especially with azoles)

📚 More Information

  • CAPA is a recently recognised entity, requiring close coordination between ICU, respiratory, and infectious disease teams.

  • Early antifungal treatment improves outcomes, but diagnosis is often delayed due to overlapping features with COVID-19 pneumonia.

  • Resources: ECMM/ISHAM CAPA definitions, aspergillosis.org

by GAtherton