Sinusitis in Patients with ABPA

When to suspect it, when to investigate, and when to refer

Why this matters

Patients with allergic bronchopulmonary aspergillosis (ABPA) are usually managed as having a lung disease. Diagnosis, monitoring, and treatment focus appropriately on the chest, immunology, and asthma control.

However, ABPA occurs within a single continuous airway, extending from the nose and sinuses to the lungs. Disease in the upper airway can coexist with, exacerbate, or complicate lower airway inflammation — yet sinus disease is not routinely assessed in ABPA care pathways.

This article outlines:

What is known about sinus disease in this context
Which symptoms should raise suspicion
When investigation or ENT referral should be considered
What GPs and non-specialists can reasonably do

The united airway: a brief reminder

The upper and lower airways share:

Type 2 (eosinophilic) inflammation
Immunoglobulin E–mediated immune responses
Common triggers, including allergens and fungi

Chronic rhinosinusitis is common in asthma and severe asthma, and treatment of sinus disease can improve lower airway outcomes in some patients.
ABPA sits within this same inflammatory spectrum, even though its management is lung-centred.

Sinus disease in ABPA: what is (and isn’t) known

What we know

Chronic rhinosinusitis is common in patients with asthma and severe asthma
Sinus disease may be symptomatic or relatively silent
ABPA guidelines do not mandate routine ENT review or sinus imaging
ENT involvement, therefore, varies widely between centres

What we do not know

Whether routine ENT assessment improves ABPA outcomes
Which ABPA patients benefit most from sinus intervention
The optimal timing for ENT referral in ABPA

As a result, clinical judgement remains central.

Symptoms that should prompt consideration of sinus disease

Sinusitis in ABPA patients does not always present with classic “blocked nose and facial pain”.
Key symptoms include:

Common but often overlooked

Persistent post-nasal drip
Foul, bitter, metallic, or “infected” taste in the mouth
Throat clearing, chronic cough
Thick or sticky mucus sensation
Symptoms are worse on waking or lying flat

More typical sinonasal features

Nasal blockage or congestion
Facial pressure or fullness
Reduced or altered sense of smell
Nasal crusting or discharge

Contextual clues

Poor durability of response to steroids or antifungals
Recurrent “flares” without clear chest triggers
Coexisting severe asthma or nasal polyps
Symptoms are worse in damp or mould-affected housing

A persistent foul taste in the mouth is a recognised symptom of chronic sinus disease, usually due to post-nasal drainage of inflamed secretions.

Damp homes and sinus disease

Living in damp or mould-affected environments is associated with:

Higher rates of chronic rhinosinusitis
Upper airway irritation and inflammation
Allergic sensitisation to fungal spores

In most cases, this results in inflammatory or allergic sinusitis, not invasive fungal infection.
Fungal involvement may act as an immune trigger, even when not labelled as “fungal sinusitis”.

Fungal sinusitis: rare vs under-recognised

It is important to distinguish between entities:

Type	Frequency	Key point
Invasive fungal sinusitis	Rare	Usually immunocompromised; dramatic presentation
Fungal ball (mycetoma)	Uncommon	Usually obvious on CT
Allergic fungal rhinosinusitis	Likely under-recognised	Requires active suspicion

Allergic fungal rhinosinusitis overlaps biologically with ABPA:

IgE-mediated
Eosinophilic inflammation
Thick allergic mucin

It is not routinely sought, so it may be under-diagnosed in at-risk groups.

What GPs and non-specialists can reasonably do

1. Take upper airway symptoms seriously

Especially in ABPA or severe asthma patients with:

Persistent post-nasal symptoms
Foul taste
Recurrent unexplained deterioration

2. Examine the nose and throat

Look for polyps, discharge, and crusting
Note mouth breathing or altered voice quality
Check dentition (to exclude dental causes)

3. Consider imaging when symptoms persist

CT sinuses (not plain X-ray) is the imaging of choice
Particularly appropriate if symptoms last >8–12 weeks or recur

4. Refer to ENT when:

Symptoms are persistent or progressive
CT shows significant sinus disease
There is a poor response to standard medical therapy
There is diagnostic uncertainty

Referral does not imply surgery — ENT input may be diagnostic or medical.

What this article is not saying

It does not suggest that all ABPA patients need an ENT referral
It does not claim that sinus treatment improves ABPA outcomes
It does not override existing guidelines

It does suggest that earlier consideration of the upper airway is reasonable in selected patients.

Key take-home points for clinicians

The airway functions as a single inflammatory system
Sinus disease may be subtle, under-reported, or atypical
A foul taste in the mouth is a meaningful symptom
Damp or mould exposure increases sinus disease risk
ENT referral is appropriate when symptoms persist or recur
Evidence gaps remain — but clinical vigilance is justified

In summary

ABPA is managed as a lung disease, but patients live with a whole airway.
Recognising when sinus disease may be contributing can help explain persistent symptoms and guide appropriate referral — without over-investigation or over-treatment.

by GAtherton

ABPA and Work: What a Patient Poll Tells Us About Employment, Health, and Real-World Impact

An article for patients, GPs, and non-specialist healthcare professionals

Allergic bronchopulmonary aspergillosis (ABPA) is often discussed in terms of lung function, immunology, and imaging. Far less often do we talk about its impact on everyday life, particularly on a person’s ability to work.

A poll run within the National Aspergillosis Centre patient community asked a simple but powerful question:

Who is still able to work while living with ABPA – and who has had to stop or retire?

The responses provide an important insight into the functional and socioeconomic burden of ABPA.

Key findings from the poll (patient-reported)

Working full time: 17%
Working part time (days or hours): 18% combined
Not working: 30%
Retirement age: 21%
Retired early for health reasons: 12%
Currently on sick leave / full-time carer / pre-diagnosis: small but notable groups

Even allowing for the informal nature of a social media poll, the overall pattern is clear.

What this tells us

1. Sustained full-time work is uncommon in ABPA

Fewer than one in five respondents were able to work full time. Even among those still working, many described reduced hours, flexible arrangements, or fragile employment dependent on day-to-day health.

ABPA is often incompatible with predictable, high-demand working patterns.

2. ABPA frequently leads to work loss or early retirement

A substantial proportion of respondents were either:

No longer working at all, or
Retired earlier than planned specifically because of health

This is particularly striking given that ABPA often affects people during their working years and may coexist with asthma, bronchiectasis, or long-term steroid use.

3. “Retirement age” can hide health-forced exit

Some respondents selected “retirement age,” but accompanying comments revealed that many:

Left work earlier than expected
Changed careers or reduced responsibilities years before retirement
Worked through ill health until they no longer could

This matters when interpreting employment statistics: health-driven work loss may be underestimated.

4. Unpaid work and instability are often overlooked

The poll also highlighted:

People currently on prolonged sick leave
Full-time unpaid carers
Individuals still awaiting diagnosis but already struggling to work

These groups are frequently invisible in employment data, yet represent significant personal and societal impact.

Why ABPA affects the ability to work

For patients and non-specialists, it is important to understand that work difficulties in ABPA are not simply due to “asthma symptoms.”

Common contributors include:

Chronic breathlessness and cough
Severe fatigue and post-exertional exhaustion
Recurrent chest infections
Steroid side-effects (muscle weakness, bone disease, mood changes, diabetes risk)
Unpredictable flare-ups requiring rest, antibiotics, or hospital care
Cognitive and emotional burden of long-term illness

Together, these make consistent attendance, physical work, and high cognitive load difficult to sustain.

Implications for patients

Difficulty working is not a personal failure
Many others with ABPA face similar challenges
Adjustments, reduced hours, or stopping work altogether may be medically appropriate
Asking for support is reasonable and justified

Implications for GPs and non-specialist clinicians

Employment status should be considered a key outcome of disease control
Fit notes, occupational health input, and benefits documentation are part of holistic care
ABPA is a fluctuating condition – patients may cope for periods and then deteriorate
Statements such as “lung function is stable” do not always reflect real-world functioning

Understanding the work impact helps clinicians better support patients in consultations, reports, and advocacy.

Implications for systems and policy

This poll reinforces that ABPA carries a significant socioeconomic burden, including:

Reduced workforce participation
Early retirement
Increased reliance on health and social support systems

Any assessment of disability, employment capability, or long-term planning must take into account:

Variability over time
Treatment burden
Side-effects of necessary medications

In summary

This patient poll sends a consistent message:

ABPA commonly limits the ability to work, often leading to reduced hours, unstable employment, or early exit from the workforce.

For patients, this experience is shared and valid.
For clinicians, it is a reminder that ABPA is not just a radiological or immunological diagnosis, but a life-limiting condition with real-world consequences.

by GAtherton

Season’s Greeting

As the year draws to a close, we would like to send warm wishes to everyone in the aspergillosis community — patients, families, carers, clinicians, nurses, scientists, and all professionals working to improve care and understanding.

Living with aspergillosis, or supporting those who do, often requires resilience, patience, and compassion. Throughout this year, we have seen remarkable strength from patients, dedication from healthcare teams, and generosity of spirit across our wider community.

At this time of reflection and renewal — whether you mark Christmas, another festival, or simply the turning of the year — we hope you find moments of rest, comfort, and connection. May the days ahead bring steadier health where possible, renewed energy, and continued progress in care, research, and support.
Thank you for being part of this community.

With warmest wishes for peace, kindness, and hope — now and into the New Year.

by GAtherton

Potential respiratory hazards of fungal exposure in the residential indoor environment: a systematic review (2025)

Summary of the 2025 Systematic Review for Non-Specialists & Patients

Read full paper here: Potential respiratory hazards of fungal exposure in the residential indoor environment: a systematic review - ScienceDirect

What was this review about?

This review looked at all the scientific evidence from 1990–2025 on how indoor fungi (moulds) in homes affect people’s breathing and general respiratory health. It examined 94 studies, mapping out where fungi come from, which species appear most often, and how they affect the lungs, nose, throat, and immune system.

Key Findings in Plain Language

1. The biggest sources of indoor mould are dampness and building damage

Homes with water leaks, damp walls, damaged materials and poor ventilation are the most common sources of fungi—especially Aspergillus and Penicillium. These thrive in wet building materials, bathrooms, kitchens, drains, air-conditioning systems and even water dispensers.

2. Indoor fungi are strongly linked to a wide range of respiratory symptoms

Across many countries, indoor fungal exposure was associated with:

Asthma and asthma flare-ups
Allergic rhinitis (blocked or runny nose)
Chronic cough and throat irritation
Adenoid enlargement in children
Hypersensitivity pneumonitis (allergic inflammation of the lungs)
Reduced lung function
Even pulmonary haemorrhage in rare cases

The review shows that even everyday exposure—not just visibly mouldy homes—can worsen respiratory health.

3. Some fungi are more strongly associated with illness

Important associations include:

Aspergillus → asthma symptoms, COPD exacerbations, throat irritation, hypersensitivity reactions
Penicillium → asthma, allergic rhinitis, hypersensitivity pneumonitis
Alternaria → childhood asthma risk
Candida & Fusarium → present in wet areas such as bathrooms and may affect vulnerable individuals

4. The geographic picture is uneven

Most research comes from high-income, temperate countries. There are major evidence gaps in tropical and subtropical regions, where humidity is high and fungal exposure is likely worse. This limits current global understanding of risk.

5. Prevention works — but public awareness is low

Simple actions (cleaning, improved ventilation, addressing leaks, correct humidity ranges) can radically reduce fungal burden. One study showed 80–90% reduction in airborne mould counts after residents were given basic remediation advice.

What’s New or Important in This 2025 Review?

1. A fully integrated “source → species → disease → location” map

The review is the first to link fungal sources, the exact fungi found, the diseases they cause, and where the evidence comes from, creating a multi-layered evidence map. This helps identify:

Which household features pose the highest risk
Which fungi are clinically most important
Where research gaps exist

2. Highlights the major global research imbalance

It emphasises that very little evidence exists from low-income and tropical areas—where exposure may be far more severe. This is a call for equity and better global surveillance.

3. Shows that fungi may affect more than the lungs

The review notes new evidence that fungal exposure may also influence neurological and immune-mediated symptoms, suggesting mould exposure could have broader health effects than traditionally recognised.

4. Identifies major gaps in identifying which fungal species cause harm

Many studies only measure “mould level” without identifying the fungus. The review argues for better fungal detection technologies, such as:

Portable real-time samplers
Multi-omics (DNA, RNA, metabolites)
Long-term cohort studies

These tools could finally clarify which fungi cause which illnesses.

5. Strong emphasis on emerging technologies for prevention

Including:

UV and photocatalytic TiO₂ devices
Improved antifungal cleaning agents
Building materials designed to resist mould growth
Volcanic minerals and clays that absorb harmful compounds

Why This Review Matters (for Patients, Carers, and Clinicians)

1. It shows mould is not “just an allergy problem”

Indoor fungi can worsen or trigger asthma, COPD, hypersensitivity pneumonitis, chronic sinus issues, and may even influence immune and neurological health. This validates patient experiences where damp homes worsen symptoms.

2. It provides strong evidence for housing-related health advocacy

Patients can use this to:

Request landlord repairs
Support home assessments
Advocate for rehousing if severe mould is present
Justify humidifier/dehumidifier use, and ventilation improvements

3. It highlights the importance of early remediation

Even simple cleaning and remediation steps can dramatically reduce mould burden and symptoms—important for families, vulnerable groups, and those with chronic lung disease.

4. It gives clinicians a clearer evidence base

Respiratory teams can use this to:

Recognise when housing contributes to disease flare-ups
Understand which conditions are most strongly linked to indoor fungi
Make better-informed referrals for environmental health assessments

5. It builds a scientific foundation for future guidelines

The authors point out that national building codes, indoor air quality policies, and public health guidance lag behind the evidence—and this review is intended to inform future regulation.

Who Does This Help Most?

Patients with:

Asthma
Allergic bronchopulmonary aspergillosis (ABPA)
Aspergillus bronchitis
COPD (especially those with fungal-associated exacerbations)
Hypersensitivity pneumonitis
Children with recurrent respiratory infections
Anyone living in damp, mouldy, water-damaged, or poorly ventilated homes

Clinicians:

Respiratory physicians, GPs, ENT specialists, allergists, immunologists.

Policy & Housing Professionals:

Public health teams, environmental health officers, social landlords, housing associations.

Researchers:

Those developing diagnostics, fungal exposure studies, indoor air quality monitoring, or patient-centred environmental interventions.

by GAtherton

Using Radiopaedia and Online Imaging Resources Safely: What Expert Patients and Non-Specialist Clinicians Need to Know

Online radiology education platforms such as Radiopaedia (see aspergillosis images here) have transformed access to medical knowledge. They provide high-quality explanations of imaging findings, annotated examples, and differential diagnoses that are invaluable for learning, teaching, and patient empowerment.

For expert patients living with long-term conditions, and for non-specialist clinicians working outside radiology, these resources can greatly improve understanding of scan reports and discussions with healthcare teams. However, it is important to understand what these tools can – and cannot – do.

Radiopaedia is an educational resource, not a diagnostic service

Radiopaedia is designed to teach pattern recognition and radiological reasoning, not to provide individual diagnoses. The cases shown are curated examples, often with classic features, and are presented without the full clinical complexity that accompanies real patients.

Real-world imaging interpretation requires integration of:

Clinical history and symptoms
Laboratory results (for example inflammatory markers, microbiology, immunology)
Prior imaging and disease progression
Treatment history and response
Knowledge of common mimics and incidental findings

This clinical synthesis cannot be replicated by reviewing example images alone.

Why expert radiologist review still matters

For many diagnoses, there is no substitute for a radiologist formally reviewing and interpreting the imaging.

This is particularly true when:

Findings are subtle or evolving
Multiple conditions coexist (for example bronchiectasis, infection, scarring, and inflammation together)
Imaging appearances overlap between diseases
Treatment decisions depend on small but important changes over time

Radiologists are trained to recognise not only “textbook” appearances, but also atypical, incomplete, or misleading patterns, and to weigh uncertainty appropriately in their reports.

Imaging patterns are rarely diagnostic in isolation

Many imaging features are non-specific. For example:

Cavities can be caused by infection, inflammation, malignancy, or prior disease
Nodules may represent infection, scarring, inflammation, or benign change
Mucus plugging can occur in asthma, infection, allergic disease, or chronic airway disease

Educational resources often present differential diagnoses clearly, but deciding which diagnosis applies to a specific patient requires clinical judgment and experience.

A particular note for chronic lung and fungal disease

In complex conditions such as chronic lung disease, allergic lung disease, or fungal infections, imaging interpretation is especially nuanced. Appearances may change slowly, fluctuate with treatment, or overlap with other long-standing abnormalities.

Small changes that are significant to a specialist team may appear minor or ambiguous when viewed without context. Conversely, dramatic-looking findings may represent stable or inactive disease.

This is why specialist radiology input, often alongside multidisciplinary discussion, remains essential.

How expert patients and clinicians should use Radiopaedia

Used appropriately, Radiopaedia can:

Improve understanding of scan terminology
Help frame informed questions for clinicians
Support education and shared decision-making
Aid non-specialists in recognising when further advice is needed

It should not be used to:

Self-diagnose based on image similarity
Override formal radiology reports
Draw conclusions without clinical correlation

The key message

Radiopaedia and similar platforms are powerful educational tools. They enhance knowledge, confidence, and communication. But for many diagnoses, they complement rather than replace expert radiologist assessment.

The safest and most effective approach is to use educational resources alongside formal imaging reports, specialist input, and clinical discussion — not instead of them.

by GAtherton

Beyond guidelines: what do I need to know when dealing with fungal diagnostics?

Cornelia Lass-Flörl. Clinical Microbiology and Infection (2025)

PIIS1198743X2500357X

Why this paper matters

Diagnosing invasive fungal infections (including aspergillosis) remains difficult in real-world practice. Guidelines exist, but patients and clinicians often experience confusing or apparently conflicting test results. This narrative review explains why that happens and how results should be interpreted in context, particularly for Aspergillus infections.

Key messages relevant to aspergillosis

1. Your immune system strongly affects test results

The paper clearly explains that diagnostic tests behave very differently depending on immune status:

In neutropenic or heavily immunosuppressed patients, antigen tests such as galactomannan tend to perform better, while antibody tests often fail.
In immunocompetent or non-neutropenic patients, including many with chronic pulmonary aspergillosis (CPA), Aspergillus IgG antibody tests are often positive and clinically useful.
This helps explain why some patients are told their blood tests are “negative” despite ongoing disease.

2. Where the sample comes from matters

For lung aspergillosis:

Bronchoalveolar lavage (BAL) samples are far more informative than blood.
Blood cultures are usually unhelpful for Aspergillus, as the fungus rarely circulates in the bloodstream.
A positive sputum culture may represent colonisation rather than infection, especially in people without severe immune suppression.

This reinforces an important patient message: a single test result is rarely enough.

3. Antifungal treatment can hide infection

Starting antifungal therapy early can:

Make cultures negative
Reduce antigen levels (e.g. galactomannan)
Complicate microscopy interpretation

This explains why some patients experience false reassurance from negative tests after treatment has already begun. Serial testing and clinical judgement are often more informative than a single result.

4. False positives and cross-reactivity are common

The review highlights important pitfalls:

β-D-glucan can be positive due to bacterial infections or medical materials, not just fungi
Galactomannan can cross-react with other fungi (e.g. Fusarium)
Mixed infections can occur in immunosuppressed patients

This supports a cautious interpretation of “positive” results and explains why clinicians may hesitate to diagnose aspergillosis based on one test alone.

5. Colonisation vs infection is a central challenge

A particularly relevant section for aspergillosis patients explains:

Aspergillus can live in airways without causing invasive disease
Diagnosis relies on combining symptoms, imaging, risk factors, and multiple tests
This reflects the lived experience of many patients with bronchiectasis, asthma, or chronic lung disease.

Strengths of the paper

Written by a leading international mycology expert
Pragmatic and clinically grounded
Explains why guidelines don’t always fit individual patients
Particularly strong on Aspergillus diagnostics, including CPA and invasive disease

Limitations

Focuses mainly on invasive fungal infections; allergic and chronic syndromes are discussed less
Aimed primarily at clinicians and laboratories, not patients

Take-home message for patients

There is no single “definitive” test for aspergillosis. Results depend on immune status, sample type, timing, and prior treatment. Negative tests do not always mean absence of disease, and positive tests do not always mean active infection.

This paper strongly supports the multidisciplinary, experience-based approach used in specialist centres such as the National Aspergillosis Centre.

by GAtherton

The Chief Medical Officer’s Annual Report 2025: Infections

What this document is

The Chief Medical Officer’s Annual Report 2025: Infections is a major national review produced by the Chief Medical Officer for England, Professor Chris Whitty. It is a comprehensive, 371-page assessment of:

Current infectious disease threats in England
How infections are changing (ageing population, travel, globalisation, antimicrobial resistance)
What the NHS, public health services, and government need to do to protect the public
Key topics including vaccines, fungal infections, infection in older adults, housing, climate change and more

It includes contributions from national experts—including a full chapter dedicated to fungal infections (section 4.2) and others that touch on issues highly relevant to aspergillosis patients (vaccination, antimicrobial resistance, respiratory infections, housing, and vulnerable populations)

cmo-annual-report-2025-infectio…

Why it is published

The report is published each year to:

1. Advise Government

It sets out the CMO’s expert recommendations on how England should prepare for current and future infection threats, including pandemics, AMR, and emerging fungal pathogens.

2. Influence NHS planning and investment

The report highlights weaknesses in the system and proposes reforms.
This year’s report strongly emphasises:

Better infection services
Stronger surveillance
Improving vaccine uptake
Protecting older adults (now the group with most infection-related deaths)
Expanding superspecialist expertise—including fungal disease expertise

3. Inform clinicians, researchers, and public health professionals

It provides a current consensus on infectious disease trends, evidence, and priorities.
Chapters are written by leading UK experts in each field (e.g., fungal infections, antimicrobial resistance, vaccines, imported infections)

4. Educate the public and third-sector organisations

The report is open-access and intended to help the public understand why infection preparedness matters and why actions like vaccination, stewardship, and early diagnosis are essential.

Who reads it

The report is widely used across:

Government

Department of Health and Social Care
UKHSA
Cabinet Office (emergency planning)
Local authorities

NHS and clinical services

Infectious disease physicians
Respiratory teams
Microbiology and virology specialists
Primary care networks
ICS / ICB teams planning local services

Researchers and academic institutions

It sets the direction for future research and funding priorities, including for fungal disease and AMR.

Charities, patient organisations and advocates

Groups representing people with chronic, infectious, or respiratory illness read the report to understand system-level changes and advocate for patient needs.

Industry and diagnostics developers

They monitor future needs for antifungals, vaccines, and diagnostic tools.

Why this report is important for aspergillosis patients

Several aspects of the 2025 report directly relate to people with ABPA, CPA, SAFS or Aspergillus bronchitis.

1. Fungal infections are recognised as a major emerging threat

The report includes a dedicated chapter on fungal infections (section 4.2), describing:

Rising antifungal resistance
Expanding fungal threats globally
The importance of specialist mycology expertise
The risks from agricultural fungicides
The need for improved surveillance and diagnostics

This formal recognition strengthens the case for specialised centres like the National Aspergillosis Centre.

2. It highlights the need for superspecialists in rare and imported infections—including fungal disease

The CMO states that England requires:

“superspecialists to provide advice on and management of infections including… rarer [infections] such as fungal infections.”

cmo-annual-report-2025-infectio…

This directly supports the role and expansion of the NHS mycology services, which Aspergillus patients rely on for accurate diagnosis and treatment.

3. It reinforces the importance of antimicrobial and antifungal stewardship**

For people with aspergillosis, this matters because:

Resistance to azoles is rising—and the report explicitly mentions agricultural fungicides as part of the problem.
Stewardship ensures patients receive appropriate antifungals, monitored carefully and adjusted safely.
It argues for more drug development, which is essential because current antifungal options are limited.

4. It emphasises diagnosing infection in older adults

Older adults are increasingly vulnerable to infections and complications, especially respiratory ones.
The report stresses that:

Infection in older adults often has more serious consequences
Early diagnosis is essential
Access to specialist care must improve

Since many aspergillosis patients are older with complex lung disease, this section validates the need for better recognition and earlier referral.

5. Housing and damp are recognised as infection risks

The chapter Housing and Infection (section 7.2) discusses how substandard housing—including damp and mould—drives respiratory illness.
Although not Aspergillus-specific, it gives important public health backing for patients needing remediation and better housing conditions.

6. The report strengthens the case for national fungal surveillance

Key recommendations include:

Improving surveillance of antimicrobial and antifungal resistance
Better mapping of emerging pathogens
More research into fungal diseases

These system-level improvements directly benefit aspergillosis patients by helping earlier detection and better treatment options.

7. It raises awareness of fungal disease at national level

Simply being included in a flagship CMO report is important.
It means:

Policymakers can no longer overlook fungal infections
Funding for mycology services becomes easier to justify
Clinicians across the NHS will become more aware of CPA, ABPA and related diseases
It helps reduce the years-long diagnostic delays many patients face

In short — why Aspergillus patients should care

The 2025 CMO Annual Report is one of the most influential documents shaping future infectious disease strategy in England. For aspergillosis patients, it is important because:

✓ Fungal infections are explicitly highlighted as a growing threat

✓ Specialist mycology services are recognised as essential

✓ Antifungal resistance is identified as a major risk requiring action

✓ Better diagnosis and monitoring of at-risk groups is encouraged

✓ Housing, climate, age and vulnerability—all major issues for patients—are addressed

✓ It strengthens the case for investment in NAC and wider mycology networks

This report can be used by patient groups, NAC advocates, and healthcare professionals to press for:

More referrals
Better awareness among GPs and respiratory teams
Expanded mycology diagnostic capacity
Greater research funding
Better antifungal stewardship
National fungal surveillance

by GAtherton

Aspergillosis Research Highlights — Week in Review (Last 7 Days: Week 50)

Seven key publications: pathogenicity, diagnostics, resistance, treatment, maxillofacial disease, and ABPA in COPD.

1. Comparative Overview of A. fumigatus, A. flavus, and A. niger

Rafique et al., J Infect Public Health, 2025
DOI: 10.1016/j.jiph.2025.103070

What this adds

A major comparative review (2000–2025) of the three most clinically relevant Aspergillus species.
Highlights broad clinical spectrum: allergy → chronic disease → invasive aspergillosis.
Identifies species-specific concerns:
- A. fumigatus: globally dominant, rapidly evolving triazole resistance.
- A. flavus: important in warmer climates; high aflatoxin relevance.
- A. niger: relatively lower virulence but significant in sinus disease.
Public health message: surveillance gaps persist, especially for non-fumigatus species.

Why it matters

A strong reference paper supporting the WHO prioritisation of Aspergillus, and reinforcing the need for:

Better diagnostics
Species-level identification
Environmental resistance monitoring

2. GFP Fusion Protein Proteolysis in A. fumigatus

Paul & Moye-Rowley, G3 (Bethesda), 2025
DOI: 10.1093/g3journal/jkaf295

What this adds

Fundamental molecular biology study revealing regulated degradation pathways of green fluorescent protein (GFP) fusion proteins inside A. fumigatus.
Demonstrates how the fungus controls protein turnover under stress conditions.

Why it matters

Advances tools for fungal cell biology.
Supports drug development by clarifying pathways involved in stress response and antifungal tolerance.
Reinforces WHO’s classification of A. fumigatus as one of the four most critical fungi to study.

3. ABPA in COPD: Case Series + Review

Ren et al., BMC Pulmonary Medicine, 2025
DOI: 10.1186/s12890-025-04027-8

What this adds

11 COPD cases with confirmed Allergic Bronchopulmonary Aspergillosis — highlighting:
- Under-recognition in COPD
- Overlap with chronic bronchitis/bronchiectasis symptoms
- Frequent misdiagnosis as recurrent infections or COPD exacerbations
Provides diagnostic guidance and a literature synthesis.

Why it matters

Significant implications for case finding across the UK.
Supports NAC messaging: ABPA is not only an asthma disease.
Reinforces need for:
- IgE/IgG screening
- Early CT imaging
- Awareness among COPD teams and primary care

4. EL219: Next-Generation Polyene Antifungal

Youssef et al., AAC, 2025
DOI: 10.1128/aac.01400-25

What this adds

Animal model evidence that EL219, a modern polyene, is effective against:
- Triazole-susceptible A. fumigatus
- Azole-resistant isolates
- Difficult species (A. lentulus, A. calidoustus)

Why it matters

Highly relevant to rising global antifungal resistance.
Early indication that EL219 may fill a clinical gap similar to (or complementary to) olorofim and fosmanogepix.
Suggests strong activity even in immunosuppressed models.

5. Misidentification & Triazole Resistance in Aspergillus tubingensis

Wang et al., JAMA Network Open, 2025
DOI: 10.1001/jamanetworkopen.2025.43630

What this adds

Large Southern California population study showing:
- Frequent misidentification of A. tubingensis as A. niger.
- Notable azole resistance rates in correctly identified isolates.
Stresses need for genomic sequencing or MALDI-TOF with updated libraries.

Why it matters

Strong evidence that misidentification leads to:
- Inappropriate antifungal therapy
- Poor outcomes
Supports calls for expanded diagnostic reference services such as MRCM.

6. 50-Year Review of Oral Fungal Infections in Thailand

Kosanwat et al., Clinical Oral Investigations, 2025
DOI: 10.1007/s00784-025-06685-8

What this adds

Longitudinal study: 29% of deep infections involved aspergillosis.
Mean age 62 → older adults most affected.
Many cases were mucormycosis, histoplasmosis, or aspergillosis presenting late.

Why it matters

Shows that oral/maxillofacial fungal disease remains under-recognised globally.
Relevant to dental teams → better imaging + biopsy protocols needed.
May help NAC/CARES identify referral pathways from dental medicine.

7. Management of Maxillary Sinus Aspergillosis with Implants

Khoury et al., Int J Oral Implantol, 2025

What this adds

Real-world 3–10 year follow-up of 11 patients.
Standardised approach:
- Surgical clearance
- Antifungal therapy
- Successful implant-prosthetic rehabilitation

Why it matters

Demonstrates excellent long-term outcomes when sinus aspergillosis is properly treated.
Practical implications for:
- ENT surgeons
- Oral surgeons
- Implant dentistry
Supports inclusion of aspergillosis in sinus disease differential diagnosis.

Cross-Cutting Themes Emerging This Week

1. Under-recognition and misidentification

ABPA in COPD
Misidentified A. tubingensis
Asymptomatic sinus disease
Oral/maxillofacial deep fungal infections

→ Key NAC message: We are missing cases in primary care, COPD clinics, ENT, and dentistry.

2. Antifungal resistance remains a central threat

Contemporary reviews of species-specific resistance patterns
EL219’s promise against resistant species
Misidentification leading to incorrect susceptibility assumptions

3. Need for better diagnostics and reference centres

Species-level identification is essential
Supports arguments for expansion of MRCM-style national services

4. The clinical spectrum is broad

From allergy (ABPA in COPD) → chronic sinus disease → deep oral infections → invasive pulmonary aspergillosis.
This reinforces the message: aspergillosis is multi-specialty, not confined to respiratory medicine.

Weekly NAC/MRCM Take-Home Messages

COPD teams should screen for ABPA more frequently—especially in patients with recurrent “infective exacerbations.”
Species-level identification is increasingly important; misidentification contributes to treatment failure.
New antifungals like EL219 show promise against resistant strains including A. lentulus.
Dental and ENT teams need better awareness: sinus and oral fungal infections remain overlooked but treatable.
Global reviews show growing public health significance of Aspergillus species—aligning with WHO priorities.

by GAtherton

⭐ Severe Asthma with Fungal Sensitisation (SAFS): The Hidden Burden Behind Difficult Asthma

Estimated prevalence: 15–30% of severe asthma patients show fungal sensitisation.

Severe Asthma with Fungal Sensitisation (SAFS) describes a group of patients with severe asthma who show sensitisation (allergy) to Aspergillus or other environmental moulds but do not meet criteria for ABPA. These patients often experience persistent inflammation, breathlessness, mucus production, and exacerbations that are not adequately controlled by standard asthma therapies.

Although SAFS is common in severe asthma clinics, it remains poorly recognised, frequently mislabelled, and rarely discussed in routine practice. Yet identifying SAFS is crucial because it opens the door to specific interventions — including antifungals or targeted biologics — that can improve symptoms and reduce hospital admissions.

⭐ How Common Is SAFS?

SAFS is more common than ABPA and CPA combined in asthma services.

Population	Estimated prevalence
Moderate asthma	~5%
Severe asthma	15–30%
Patients with frequent exacerbations	up to 40%
ABPA-negative patients with mucus plugging	high likelihood

Across the UK, this represents tens of thousands of people.

⭐ Why SAFS Is Missed

1. The diagnosis is not widely understood

Unlike ABPA or CPA, SAFS lacks:

universally agreed diagnostic criteria
clear imaging features
a single confirmatory test

This leads to variability in thinking and detection.

2. Symptoms mimic uncontrolled asthma

SAFS patients typically experience:

severe breathlessness
wheeze
mucus production
airway plugging
poor response to inhalers
frequent steroid courses

These appear indistinguishable from “difficult” or “type 2–high” asthma.

3. IgE and eosinophils may be normal

Unlike ABPA:

total IgE may be modest
Aspergillus IgE may be borderline
eosinophils may fluctuate, especially with steroids or biologics

Clinicians are often looking for very high IgE levels — but SAFS patients usually don’t show them.

4. Sputum and CT scans appear non-specific

Typical imaging:

mucus plugging
small-airway thickening
variable, patchy inflammation
bronchiectasis may or may not be present

Radiologists often report these changes as:

“consistent with asthma”
“post-infective”
“non-specific inflammatory pattern”

5. The fungal link is overlooked

Many clinicians are unfamiliar with:

the role of mould exposure
sensitisation thresholds
the overlap between environmental allergy and airway disease
when antifungals are appropriate

This leads to delays in recognising fungal-driven asthma.

⭐ Who Is at Highest Risk?

1. Severe asthma patients unresponsive to maximal inhaled treatment

Particularly those with:

frequent exacerbations
nocturnal symptoms
long-term steroid use
persistently low lung function
mucus plugging events

**2. Patients sensitised to Aspergillus or multiple moulds**

Positive skin tests or specific IgE indicate airway allergy that can drive symptoms.

3. Patients with damp or mould exposure at home or work

An important environmental factor often overlooked.

4. ABPA-negative asthma patients with mucus plugging

A large proportion of these patients fit the SAFS profile.

5. Those with co-existing bronchiectasis

Bronchiectasis amplifies the inflammatory response to fungal exposure.

⭐ Specialties That Need Greater Awareness

Severe asthma services & biologics clinics
(primary diagnostic opportunity)
General respiratory clinics
Primary care & urgent care
(patients seen frequently with “persistent asthma symptoms”)
Radiology
(important for identifying mucus plugging)
Allergy/Immunology
(mould sensitisation is central to diagnosis)
Environmental health teams
(exposure to mould and dampness often perpetuates symptoms)

The National Aspergillosis Centre can provide specialist input when diagnosis is unclear or response to treatment is suboptimal.

⭐ Red Flags Suggesting SAFS

1. Severe asthma poorly controlled despite maximal inhalers

Including biologics (omalizumab, mepolizumab, benralizumab, dupilumab, tezepelumab).

**2. Sensitisation to Aspergillus fumigatus or multiple moulds**

3. Repeated mucus plugging episodes

(or “sticky mucus” symptoms)

4. More than 2–3 steroid-treated exacerbations per year

5. Asthma + bronchiectasis

Even mild bronchiectasis increases fungal risk.

6. Symptoms triggered by damp/mould exposure

7. Persistent airway inflammation despite correct inhaler technique

⭐ Misdiagnoses That Delay Recognition

“Difficult asthma”
“Brittle asthma”
“Post-viral inflammation”
“Poor adherence to inhalers”
“Asthma–COPD overlap”
“Psychogenic dyspnoea”
“Recurrent chest infections”

SAFS is a diagnosis hiding in these labels.

⭐ The Cost of Missed SAFS Diagnosis

For patients:

persistent symptoms
steroid dependence
increased risk of ABPA
progressive airway damage
hospital admissions
poor quality of life
possible career and lifestyle impact

For healthcare systems:

repeated A&E visits
asthma admissions
high biologic usage without adequate response
unnecessary antibiotics
escalating steroid toxicity
missed environmental interventions

⭐ Conclusion

SAFS is one of the most common — yet least recognised — fungal-related lung conditions. Although it lacks the dramatic imaging changes of ABPA or CPA, its impact on patients is profound.

Recognising mould sensitisation in severe asthma, understanding the role of fungal allergens, and considering targeted therapies can transform disease control. For complex cases or when the diagnosis is uncertain, referral to the National Aspergillosis Centre is recommended.

Early identification and appropriate treatment reduce steroid use, exacerbations, and long-term airway damage.

by GAtherton

⭐ Aspergillus Bronchitis: The Overlooked Condition Hiding in Plain Sight

Estimated prevalence 1–2% in bronchiectasis and chronic airway disease clinics.

Aspergillus Bronchitis (AB) is a chronic, symptomatic infection of the airways caused by Aspergillus species in people with underlying lung disease. It sits between simple colonisation and chronic pulmonary aspergillosis (CPA), and is frequently overlooked or mislabelled as “recurrent infection,” “post-viral symptoms,” or uncontrolled bronchiectasis.

Unlike CPA, Aspergillus Bronchitis does not require cavities or major structural destruction — which makes it both easier to miss and surprisingly common among people with chronic airway disease.

When recognised and treated (usually with antifungal therapy for several months), symptoms often improve significantly. But because awareness remains low, most patients cycle through unnecessary antibiotics, repeated exacerbations, and worsening airway disease before the real cause is identified.

⭐ What Exactly Is Aspergillus Bronchitis?

Aspergillus Bronchitis is defined by:

chronic productive cough
sputum growing Aspergillus species repeatedly
airway inflammation
symptoms lasting over 3 months
underlying airway disease (bronchiectasis, CF, COPD, prior TB, ABPA)
response to antifungal therapy

Unlike ABPA:

there is no allergic response,
IgE is usually normal,
eosinophils are normal or mildly elevated.

Unlike CPA:

there are no cavities on imaging,
IgG may be normal or only slightly elevated,
disease is confined to the airways, not lung tissue.

This places AB in a “grey zone” — often invisible unless specifically looked for.

⭐ Why Aspergillus Bronchitis Is Missed

1. Symptoms mimic common chronic airway disease

Typical AB symptoms include:

daily productive cough
worsening sputum thickness
breathlessness
fatigue
repeated “chest infections”
slow-to-clear mucus
crackles or wheeze

These resemble:

bronchiectasis exacerbations
COPD flare-ups
chronic infection with Pseudomonas or NTM
post-viral cough
uncontrolled asthma

Without fungal awareness, clinicians default to bacterial explanations.

2. Sputum grows multiple organisms — Aspergillus is dismissed

In bronchiectasis, sputum frequently grows:

Haemophilus
Pseudomonas
Staphylococcus
Streptococcus
NTM

When Aspergillus appears, it’s often labelled:

“colonisation”
“contaminant”
“not clinically relevant”

But repeated isolation with persistent symptoms is highly suggestive of AB.

3. IgE/IgG results may be normal

Many clinicians expect high IgE or IgG to “confirm Aspergillus disease.”
But in Aspergillus Bronchitis:

IgE is usually normal
IgG can be normal or borderline

This leads to false reassurance.

4. Radiology rarely shows overt features

CT scans in AB may show:

mucus plugging
mild bronchial wall thickening
small nodules
progression of bronchiectasis

But they do not show the cavities of CPA or classic features of ABPA.

Therefore radiologists often report scans as “no significant change” or “stable bronchiectasis.”

5. Antibiotics appear to help — temporarily

Patients often improve slightly with:

amoxicillin
doxycycline
macrolides
ciprofloxacin

This gives clinicians the impression of bacterial disease, but symptoms soon return.

6. Lack of awareness

Many specialists (even in respiratory clinics) are unaware that Aspergillus Bronchitis:

exists as a distinct clinical entity
can be disabling
responds to antifungals
predicts progression to CPA if untreated

This leads to significant diagnostic delay.

⭐ Who Is at Highest Risk?

1. Bronchiectasis

The largest risk group.
Aspergillus Bronchitis may account for 1–2% of all bronchiectasis patients, and up to 5–10% in severe or frequent exacerbator groups.

2. Cystic Fibrosis (CF)

These patients frequently grow Aspergillus but not all have ABPA — some have Aspergillus Bronchitis.

3. COPD and chronic productive cough

Especially those with:

frequent mucus plugging
repeated “infective exacerbations”
progressive sputum production

4. Post-TB airway damage

Chronic airway deformity, scarring, and bronchiectasis from old TB predispose to fungal infection.

5. Post-COVID structural disease

A new and growing risk group, especially after prolonged ICU ventilation.

6. ABPA patients

Some patients develop Aspergillus Bronchitis during steroid-dominated treatment or after stopping antifungals.

⭐ Which Specialities Need Greater Awareness?

Respiratory medicine
(especially bronchiectasis clinicians and severe asthma teams)
Infectious Diseases
(frequent respiratory presentations with chronic airway infection)
Radiology
(to recognise subtle but progressive airway changes)
Primary care
(“recurrent chest infection” or “persistent cough” patients)
Physiotherapy & airway clearance teams
(excessive sputum with fungal elements)
Cystic Fibrosis services

The National Aspergillosis Centre is the ideal referral destination when diagnosis is uncertain or symptoms persist despite typical management.

⭐ Red Flags Suggesting Aspergillus Bronchitis

1. Chronic (>3 months) productive cough + repeated Aspergillus in sputum

Even 2 positive sputums in the right clinical context should raise suspicion.

2. Bronchiectasis patient not improving on repeated antibiotics

3. Thick, tenacious mucus with black, grey, or brown plugs

4. Worsening CT bronchiectasis or mucus plugging

5. Absence of features typical for ABPA (normal IgE, no fleeting infiltrates)

6. Asthma or COPD patient with new persistent sputum

7. Partial response to antibiotics but rapid relapse

8. Unexplained fatigue and breathlessness in someone with airway disease

⭐ The Cost of Missed Aspergillus Bronchitis

If AB is not recognised early, consequences include:

repeated exacerbations
accelerating bronchiectasis
long-term airway damage
chronic inflammation
steroid overuse
unnecessary antibiotics
repeated hospitalisations
progression to CPA in some patients

For health systems, missed diagnosis leads to:

higher admission rates
inappropriate long-term antibiotic use
avoidable CT scans and investigations
greater long-term burden of CPA

But antifungal therapy — when appropriately used — can offer marked symptom improvement and reduce exacerbation frequency.

⭐ Conclusion

Aspergillus Bronchitis is a distinct, treatable form of chronic airway disease seen in people with bronchiectasis, asthma, COPD, CF, and post-TB lung damage. Yet lack of awareness means many patients are repeatedly misdiagnosed with bacterial infections or unexplained chronic cough.

Recognising red flags, reviewing sputum results carefully, and considering antifungal therapy can dramatically improve outcomes. Early referral to specialist centres such as the National Aspergillosis Centre is recommended for complex cases or uncertain diagnosis.

Early identification prevents airway deterioration — and reduces the likelihood of progression to CPA.

by GAtherton