Pulmonary eosinophilia with asthmatic syndrome: causes, symptoms, diagnosis, treatment

Bronchial asthma

Bronchial asthma (as an independent nosological form) can occur with eosinophilia of blood (usually not more than 15-20%) and "volatile" lung infiltrates, sometimes with other clinical manifestations of allergy ( urticaria, Quincke's edema, vasomotor rhinitis ).

The examination program is the same as for simple pulmonary eosinophilia.

Bronchopulmonary aspergillosis

The causative agents of aspergillosis are the fungi of the genus Aspergillus. They are widely distributed in the environment - on soil, in air, on plants, vegetables, fruits, in grain, flour and other products, especially if they are stored in heat and at high humidity. In addition, aspergillus saprophyte in a healthy person on the skin and mucous membranes, can significantly multiply and cause a serious disease in conditions of reducing the body's defenses.

Aspergillosis is more common among people in certain professions: pigeons, plantations for growing and processing red pepper, hemp, barley; workers of factories for the production of alcohol, beer, bakery industry (using saccharifying enzymes of certain types of aspergillas in the form of fungal malt); at fish factories (fermentation of fish for conservation purposes); when making soy sauce, as well as for carding wool, hair. This type of professions should be taken into account when diagnosing aspergillosis.

Currently, about 300 species of aspergillus are described. The most reliable pathogens of human and animal aspergillosis are aspergillus: A.fumigatus, A.niger, A.clavatus, A.flavus, A.candidus, A.nidulans, A.glaucus, A.versicolor.

Human infection occurs most often by inhalation and partly by nutritional methods, less often by direct contact (with damage and maceration of the mucous membranes and skin) with spores of the fungus, as well as by autoinfection as a result of the biological activation of aspergillas living on human skin.

Getting into the human body, aspergillus secretes a number of substances that have toxic effects. The most important are aflatoxins. They suppress the synthesis of DNA, mitosis of cells, affect the hemopoiesis system, cause the development of thrombocytopenia, leukopenia, anemia. Aflatoxin also causes significant damage to the liver and other organs.

Distinguish the following types of aspergillosis depending on the location of lesions:

• bronchopulmonary aspergillosis;
• extrapulmonary visceral systemic organ aspergillosis;
• aspergillosis of ENT organs;
• aspergillosis of the eye;
• aspergillosis of bones;
• aspergillosis of skin and nails;
• aspergillosis of mucous membranes;
• other manifestations of aspergillosis.

Bronchopulmonary aspergillosis is the most common form of human aspergillosis.

Allergic bronchopulmonary aspergillosis

In the pathogenesis of bronchial asthma in aspergillosis, the development of an allergic reaction of immediate type, due to the production of reactive IgE and degranulation of mast cells, is of primary importance. The affected alveoli are filled with eosinophils, subsequently granulomatous interstitial pneumonitis develops with pronounced infiltration of peribronchial tissue and interalveolar septa by plasma cells, monocytes, lymphocytes and in large numbers by eosinophils. With a steady progression of the disease, proximal bronchiectasis is formed. Hyperplasia of mucous glands and goblet cells in bronchi and bronchioles is also characteristic.

Allergic bronchopulmonary aspergillosis is characterized by bouts of bronchial asthma, the clinical picture of which corresponds to ordinary bronchial asthma, however, in addition, the patient may have an intermittent fever. Characteristic is also the separation of sputum, containing brownish or yellowish grains or plugs.

Aspergillus bronchitis, tracheobronchitis

The clinical picture of aspergillus bronchitis and tracheobronchitis is similar to the clinic of banal inflammation of the bronchi and trachea. But unlike them for Aspergillus bronchitis and tracheobronchitis is characterized by separation of cough lumps of gray color, reminiscent of cotton, sometimes purulent sputum with blood veins. Prove the aspergillous nature of the disease can only be found by aspergillas in sputum.

Aspergillus bronchopneumonia

Small-foci disseminated processes in the lungs are more common, and more often - extensive pneumonic foci.

Aspergillus bronchopneumonia proceeds clinically as bronchopneumonia of a different etiology.

Radiologic examination reveals foci of inflammatory infiltration mainly in the middle-lower sections of the lung, more often the right one. This sputum contains greyish-green flakes. The diagnosis is confirmed by the detection of aspergillas in sputum. It should be noted that in some patients the development of abscessing and necrotic aspergillus pneumonia is possible, with hemoptysis and tremendous chills appearing, and pulmonary radiographs reveal foci of infiltration with cavities of decay.

Aspergilloma of the lungs

Aspergilloma - a kind of tumor-like form of aspergillosis, characterized by the presence of a cavity in the lungs, lined with epithelium with a different amount of granulation tissue. Usually the cavity communicates with the bronchus, inside it contains fungal masses - the bisus. The cavity during movements is easily damaged by the bisus, which leads to bleeding aspergilloma.

The diagnosis of aspergilloma is based on the following symptoms:

• repeated hemoptysis (sometimes bleeding);
• chronic wavy course (febrile and subfebrile with periods of remission);
• the characteristic radiographic picture is the presence, most often in the apical segments, of the upper lobes of an "elitist, round, thin-walled cavity without perifocal infiltration with a central dimming in the form of a ball and edge luminosity as a crescent moon;
• positive serological reactions with specific antigens from aspergillus;
• repeated receipt of the same type of aspergillus from sputum, biopsy materials or bronchial washings.

Diagnostic criteria

The main diagnostic criteria for allergic bronchopulmonary aspergillosis are:

• recurrent attacks of atopic bronchial asthma;
• proximal bronchiectasis (detected radiographically or by computed tomography, bronchography is not recommended);
• a high percentage of eosinophils in peripheral blood; sputum eosinophilia;
• high level of IgE in the blood;
• recurrent pulmonary infiltrates (detected by X-ray method of investigation); they can move from one share to another;
• detection of precipitating antibodies to the aspergillus antigen;
• growth of aspergillus in sputum culture;
• the detection in the sputum of crystals of calcium oxalate - the metabolite of aspergillus;
• increased uric acid levels in the bronchial washings;
• positive skin tests with a specific allergen. The skin test can give a two-phase positive reaction: first an immediate type with a papule and erythema, and then a delayed type in the form of erythema, edema and soreness, which are manifested as much as possible after 6-8 hours.

Laboratory data

In aspergillosis sputum analysis is performed , bronchial flushing waters, phlegm from fauces are examined. The test material is treated with a 20% solution of KOH, then a microscopy of native uncolored preparations is made, and the septate aspergillus mycelium is already visible at low magnification, but especially well - at large. Often along with the mycelium, the aspergillus convex heads are found.

For the identification of the aspergillus species, and also for the purpose of isolating pure culture, the pathological material is sown to the Chapeka nutrient media, the wort turpentine, the glucuroagar Saburo.

A great diagnostic value is also the determination of serum precipitating antibodies to the aspergillus antigen and the papular erythematous skin reaction to the aspergillus antigen.

Survey program

1. Analysis of subjective manifestations of the disease and a professional anamnesis.
2. Common blood tests, urine tests.
3. Sputum analysis - physical properties (color, odor, transparency, presence of lumps of yellow and brown color), cytological examination (number of eosinophils, neutrophils, lymphocytes, atypical cells), research on the presence of mycelium aspergillus, sputum culture on special nutrient media.
4. Immunological studies - the content of T- and B-lymphocytes, subpopulations of T-lymphocytes, circulating immune complexes, immunoglobulins, including IgE.
5. Determination of serum precipitating antibodies to the aspergillus antigen.
6. Setting a skin test with the antigene aspergillus.
7. X-ray examination of the lungs.
8. ECG.
9. Spirography.
10. Computer tomography of the lungs.
11. Consultation of phthisiatrician, oncologist, allergist.

Tropical pulmonary eosinophilia

Tropical pulmonary eosinophilia (Weingarten syndrome) is caused by invasion and further migration of larval forms of helminths of microfillarians. The main manifestations of the disease are:

• severe attacks of bronchial asthma;
• increase in body temperature to 38 ° C, sometimes - up to 39 ° C;
• symptoms of intoxication (headache, lack of appetite, weight loss, sweating);
• cough with hard-to-remove sputum mucous;
• aching, sometimes paroxysmal pain in the abdomen without a clear localization;
• systemic manifestations of the disease - an increase in peripheral lymph nodes, various skin rashes, polyarthralgia (rarely - transient polyarthritis), splenomegaly;
• focal infiltrative, often disseminated, miliary X-ray changes in the lungs;
• characteristic laboratory data - high eosinophilia (60-80%) in the peripheral blood, high IgE, false positive Wasserman reaction (the sign is frequent, but not permanent).

When diagnosing this disease, great importance is given to the epidemiological anamnesis (the disease is most often observed in the inhabitants of South-East Asia, India, Pakistan), the detection of microfillarians in a thick drop of blood and the detection of antiphilariasis antibodies in the blood by the complement fixation reaction.

[1], [2], [3], [4], [5], [6], [7], [8], [9]