Introduction to Aspergillosis for Non-Specialist Clinicians
Aspergillosis describes a group of lung diseases caused by Aspergillus species—most commonly A. fumigatus. While exposure to spores is universal, disease mainly affects people with asthma, cystic fibrosis, COPD, previous tuberculosis, sarcoidosis, structural lung disease, or immunosuppression. Conditions range from allergic (e.g., ABPA) to chronic (CPA, Aspergillus bronchitis) to invasive disease (IA). Early recognition prevents years of morbidity from repeated “chest infections” and steroid exposure.
At a glance
- Think Aspergillus in difficult-to-control asthma, unexplained bronchiectasis, or cavitary/fibrosing lung disease.
- Start with Total IgE and Aspergillus-specific IgE/IgG; arrange imaging (CXR → CT if needed).
- Refer to local Respiratory/ID teams first; escalate to NAC for complex/refractory cases.
- NAC provides remote Advice & Guidance, virtual MDT, therapeutic drug monitoring (TDM) and resistance testing.
- Check azole interactions at initiation and when co-medications change.
- Upskill rapidly via RCGP eLearning and MIMS Learning.
Clinical spectrum of aspergillosis
| Type | Typical host | Key features | Initial investigations |
|---|---|---|---|
| Allergic Bronchopulmonary Aspergillosis (ABPA) | Asthma / CF | Worsening wheeze, mucus plugs, fleeting infiltrates, high Total IgE, positive Aspergillus-specific IgE/IgG | Total IgE, Aspergillus IgE/IgG, CXR |
| Severe Asthma with Fungal Sensitisation (SAFS) | Severe/difficult asthma | Fungal sensitisation, poor control without ABPA criteria | Allergy testing or IgE |
| Chronic Pulmonary Aspergillosis (CPA) | COPD, post-TB, sarcoidosis, post-COVID fibrosis, bullous disease | Cavities ± fungal ball, cough, haemoptysis, weight loss, fatigue | CXR/CT, Aspergillus IgG |
| Aspergillus Bronchitis | Bronchiectasis / structural lung disease | Chronic purulent sputum, recurrent infection, positive Aspergillus culture | Sputum culture, Aspergillus IgG |
| Invasive Aspergillosis (IA) | Immunocompromised, transplant, haematology, ICU | Fever, pleuritic pain, nodules on CT, rapid course | Urgent hospital admission & fungal diagnostics |
National Aspergillosis Centre (NAC)
The National Aspergillosis Centre (NAC) at Wythenshawe Hospital, Manchester University NHS Foundation Trust is the UK’s tertiary referral service for chronic and allergic aspergillosis, commissioned by NHS England as a Highly Specialised Service.
- Complex diagnosis and case review (ABPA, SAFS, CPA, Aspergillus bronchitis)
- Therapeutic drug monitoring (TDM) for itraconazole, voriconazole, posaconazole; resistance testing
- Remote Advice & Guidance (NHS e-RS) and virtual MDT for complex/uncertain cases
- Education, research and training via the Manchester NIHR BRC
Referral & professional info:
NAC – Referrals ·
Antifungal–drug interactions: why they matter
Azole antifungals (itraconazole, voriconazole, posaconazole, isavuconazole) are potent CYP450 inhibitors/inducers and interact with many commonly prescribed drugs. Consequences include toxicity (e.g., with statins, calcium-channel blockers, anticoagulants), adrenal suppression/Cushing’s with corticosteroids, and reduced azole exposure (e.g., with PPIs or enzyme inducers). Interactions are a leading cause of treatment failure and adverse events—check at initiation and whenever co-medications change.
Quick tools:
University of Manchester Antifungal Interaction Checker ·
BNF Online
Therapeutic Management
Antifungal dose management and monitoring are critical to ensure both efficacy and safety. Triazole antifungals such as itraconazole, voriconazole, posaconazole and isavuconazole display high inter-patient variability in absorption and metabolism, influenced by gastric pH, food intake, hepatic function, and drug interactions. Sub-therapeutic levels risk treatment failure and resistance, while excessive levels can cause toxicity — including hepatotoxicity, visual or neurological disturbance, skin reactions, hypertension, and QT-interval changes. Regular therapeutic drug monitoring (TDM) is therefore recommended, ideally performed through specialist centres such as the National Aspergillosis Centre (NAC), to adjust doses and interpret results in context. GPs and hospital clinicians should be alert to early signs of intolerance (fatigue, nausea, visual disturbance, rash, neuropathy, liver dysfunction) and liaise promptly with local pharmacy or NAC teams to review levels, interactions, and ongoing need for therapy.
GP & clinician training
- RCGP eLearning: Fungal lung disease & aspergillosis — recognition, testing, referral pathways for primary care:
elearning.rcgp.org.uk - MIMS Learning: Managing aspergillosis & fungal sensitisation in primary care — practical IgE/IgG interpretation and prescribing tips:
mimslearning.co.uk - BTS webinars — case-based updates on CPA, ABPA and antifungal stewardship.
Patient support & education (NAC CARES)
Clinical care is integrated with psychosocial and educational support to improve adherence and wellbeing.
- NAC CARES (Community, Awareness, Research, Education, Support): weekly online support meetings (social, wellbeing, education), patient-friendly materials on airway clearance, nutrition, mental health, medicines safety; PPIE activities; management of aspergillosis.org.
- Partner organisations: The Aspergillosis Trust; moderated patient communities (Telegram/Facebook).
Signpost newly diagnosed patients here: Patient Support at NAC.
Advice & Guidance and remote MDT pathways
Primary care (GPs)
- Request Aspergillus-specific IgE/IgG and Total IgE where indicated; arrange CXR (consider CT if abnormalities persist).
- Refer to local Respiratory/ID for further assessment; include imaging, microbiology, steroid/azole history.
Secondary care (Respiratory/ID)
- Use NHS e-RS Advice & Guidance to obtain rapid input from NAC on complex/refractory cases.
- Submit case summaries and imaging for remote NAC MDT discussion; shared-care follow-up is common.
Referral & contact: NAC – Referrals.
Evidence & key publications (CPA)
- Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Thorax. 2015;70(3):270–277.
doi:10.1136/thoraxjnl-2014-206291 - Kosmidis C, Denning DW. Pulmonary aspergillosis in chronic respiratory disease—State of the Art Review. Eur Respir J. 2015;45(1):45–59.
doi:10.1183/09031936.00157514 - Kosmidis C, et al. The burden of fungal infections in the UK. J Infect. 2017;74(S1):S27–S35.
doi:10.1016/S0163-4453(17)30132-8
Guidelines & resources
- British Thoracic Society (BTS) Aspergillosis Guideline, 2020 — comprehensive UK guidance:
brit-thoracic.org.uk - NICE Guidance — antifungals, ABPA, severe asthma, biologics:
nice.org.uk - ISHAM Working Group (2024) — ABPA diagnostic criteria update:
isham.org - Public Health England — fungal disease overview:
gov.uk - University of Manchester Antifungal Interaction Checker:
antifungalinteractions.org BNF online - Aspergillosis.org — NAC, professional and patient resources:
aspergillosis.org
Summary
Aspergillosis sits at the intersection of allergy, infection and chronic lung disease. For GPs and non-specialist clinicians, the essentials are awareness, basic screening (IgE/IgG + imaging), timely local referral, and vigilance for antifungal interactions. The National Aspergillosis Centre supports UK clinicians with remote A&G, virtual MDTs, TDM and resistance testing, and integrated patient-support services that improve outcomes and quality of life.