This fortnight’s research includes encouraging results for a treatment that may help some people with allergic bronchopulmonary aspergillosis (ABPA), as well as new studies on the relationship between severe viral infections and invasive aspergillosis.
The most important message is that promising research does not automatically change treatment today. It does, however, help clinicians and researchers identify where future care may improve.
Most important: dupilumab in ABPA
A new clinical trial tested dupilumab in 62 people aged 12 and over with asthma and ABPA. Dupilumab is a biologic medicine already used for some types of severe asthma and eczema. It works by reducing two signals involved in allergic, type-2 inflammation.
After 24 weeks, people receiving dupilumab had better lung-function improvement than those receiving placebo. They also had fewer severe respiratory flare-ups. Among people taking regular oral steroid tablets at the start of the study, 71% of those receiving dupilumab no longer needed them after 24 weeks, compared with 14% in the placebo group.
This is an encouraging early controlled trial, particularly for people whose ABPA and asthma remain difficult to manage or who experience steroid side effects. However, dupilumab is not currently an approved treatment specifically for ABPA, the study was relatively small, and longer-term results are still needed. Nobody should change treatment because of this study alone; decisions about biologics need to be made with their specialist team.
Severe influenza and invasive aspergillosis
A large study from 21 intensive-care units in China looked at people admitted with severe influenza A pneumonia. Of 542 critically ill patients, 179 developed invasive pulmonary aspergillosis.
Invasive aspergillosis was usually identified very soon after influenza began, and it was linked with poorer outcomes. Diabetes, bacterial co-infection, kidney replacement therapy and corticosteroid exposure were among factors associated with greater risk.
This study concerns people who were extremely unwell with influenza and needed intensive-care treatment. It does not mean that ordinary seasonal flu commonly causes aspergillosis, or that people living with chronic pulmonary aspergillosis (CPA) or ABPA should be alarmed after every viral illness. It does reinforce the importance of clinicians considering invasive fungal infection when someone with severe flu pneumonia is not improving as expected.
COVID-19, underlying lung disease and Aspergillus
A Korean population study of more than 550,000 people diagnosed with COVID-19 found that COVID-19 was associated with a later diagnosis of respiratory aspergillosis. Diabetes, COPD and other health conditions increased the risk further.
The study included both invasive and non-invasive forms of aspergillosis, and people with both COVID-19 and aspergillosis had poorer COVID-19 outcomes. Because this was a study of health records, it can show an association but cannot prove exactly why it occurs. For example, people needing steroid treatment are often already more seriously unwell.
Again, this should be interpreted calmly. Most people with COVID-19 will not develop aspergillosis. The findings are most relevant to people with severe infection, significant lung disease or immune suppression, and to the clinicians caring for them.
A possible new way to monitor ABPA activity
Total IgE blood testing is widely used to help monitor ABPA. A new study followed 122 people during treatment and examined whether more specific Aspergillus fumigatus IgE tests could add useful information.
One marker, called recombinant Asp f4-specific IgE, rose in all 15 people who had an ABPA exacerbation during follow-up. Total IgE rose in 12 of the 15 people.
This is interesting research, but it is not ready to replace the tests currently used in clinic. Larger studies in different centres are needed first. In future, more specific markers may help clinicians judge whether ABPA is responding to treatment or beginning to flare.
CPA and sarcoidosis
A new review examines CPA in people with sarcoidosis, particularly those with more advanced scarring and cyst-like damage in the lungs. It estimates that CPA affects around 2% of people seen in specialist sarcoidosis centres.
The review highlights the importance of recognising new or changing symptoms, using scans alongside Aspergillus-specific IgG blood tests and microbiology, and planning carefully for problems such as coughing up blood. It is a useful reminder that CPA usually develops where there is pre-existing structural lung damage; it is not simply a matter of being exposed to mould.
Azole resistance remains a worldwide concern
A worldwide review has confirmed that resistance to azole antifungal medicines in Aspergillus fumigatus is an increasing issue. Resistance can emerge during antifungal treatment, but can also arise from environmental exposure to azole-like fungicides used in agriculture.
The review does not suggest that every patient will encounter resistance. Its message is that surveillance, good laboratory testing and access to specialist advice remain important—especially when someone is not responding as expected to antifungal treatment.
What to take from this update
The dupilumab trial is the most hopeful item this fortnight. It offers stronger evidence that a targeted biologic treatment may reduce symptoms, flare-ups and steroid use for some people with ABPA.
The viral-infection studies are a reminder that severe flu and COVID-19 can occasionally create conditions in which invasive aspergillosis becomes more likely—mainly in people who are already seriously ill or vulnerable. They should improve clinical awareness, not create anxiety for everyone living with an Aspergillus-related condition.
This update summarises newly published research for patients, carers and non-specialist healthcare professionals. It does not replace individual medical advice. Please discuss any concerns about symptoms or treatment with your clinical team.
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