Chronic pulmonary aspergillosis in patients with active pulmonary tuberculosis with persisting symptoms in Uganda

Abstract

Background The occurrence of chronic pulmonary aspergillosis (CPA) among drug sensitive pulmonary tuberculosis (PTB) patients on optimal therapy with persistent symptoms was investigated. Methods We consecutively enrolled participants with PTB with persistent pulmonary symptoms after 2 months of anti‐TB treatment at Mulago Hospital, Kampala, Uganda, between July 2020 and June 2021. CPA was defined as a positive Aspergillus‐specific IgG/IgM immunochromatographic test (ICT), a cavity with or without a fungal ball on chest X‐ray (CXR), and compatible symptoms >3 months. Results We enrolled 162 participants (median age 30 years; IQR: 25–40), 97 (59.9%) were male, 48 (29.6%) were HIV‐infected and 15 (9.3%) had prior PTB. Thirty‐eight (23.4%) sputum samples grew A. niger and 13 (8.0%) A. fumigatus species complexes. Six (3.7%) participants had intracavitary fungal balls and 52 (32.1%) had cavities. Overall, 32 (19.8%) participants had CPA. CPA was associated with prior PTB (adjusted odds ratio [aOR]: 6.61, 95% CI: 1.85–23.9, p = .004), and far advanced CXR changes (aOR: 4.26, 95% CI: 1.72–10.52, p = .002). The Aspergillus IgG/IgM ICT was positive in 10 (31.3%) participants with CPA. Conclusions Chronic pulmonary aspergillosis may cause persistent respiratory symptoms in up to one‐fifth of patients after intensive treatment for PTB. The Aspergillus IgG/IgM ICT positivity rate was very low and may not be used alone for the diagnosis of CPA in Uganda.

Chronic pulmonary aspergillosis is common among patients with presumed tuberculosis relapse in Ghana

“…We observed no significant statistical difference in the rate of CPA in HIV-positive patients and CPA in HIV-negative patients (6.8% vs 10.9%), contrary to other studies. 6 , 16 , 22 , 33 Though Aspergillus serology was positive in less than 10% of our screened patients, it contributed to greater than 90% of CPA diagnosis. One CPA patient who was HIV-positive had a negative Aspergillus IgG and IgM LFA result.…”

“…The current study revealed a CPA prevalence of 9.7% among patients presenting with presumed PTB. Varying rates have also reported in Uganda 22 and Nigeria, 6 Iran, 23 Pakistan, 24 Indonesia, 15 , 21 Uganda, 16 and Brazil 25 largely due to difference in study designs, population, investigations, and sampling methods. Also, the present study identified 50% prevalence of CPA in patients with prior PTB.…”

“… 34–36 However, in Africa and Asia, A. flavus and A. niger are frequently isolated, as demonstrated in our study and elsewhere. 6 , 15 , 16 , 34 The frequent imaging findings of CPA, as stipulated in many guidelines, reported in several epidemiological studies, and considered to be more linked to CPA are cavitation, pericavitary fibrosis, and pleural thickening. 4 , 5 , 8 , 15 , 21 , 22 These three features were present in 67% – 80% of CPA cases in our study on chest radiograph and/or CT scan.…”

Importance of Aspergillus-Specific Antibody Screening for Diagnosis of Chronic Pulmonary Aspergillosis after Tuberculosis Treatment: A Prospective Follow-Up Study in Ghana

“…It is important to note, however, that their cohort included at least 42% new non-bacteriologically confirmed PTB cases, and some of them probably had CPA alongside other respiratory disorders, including asthma and chronic pulmonary obstructive disease (COPD) as an underlying condition. Similarly, another study in Uganda reported ~20% CPA incidence among PTB patients with persisting symptoms after 2 months of TB treatment [6]. In a recently published study, a possible PTB-CPA coinfection was reported, but there are still doubts with regard to the existence of a true PTB infection [17].…”

“…The prevalence of CPA as a sequel of PTB worldwide was estimated at 1.2 million in 2011 [ 4 ]. Several cross-sectional studies have been conducted on CPA as a secondary infection of PTB in different countries, and they have reported varying rates [ 5 , 6 , 7 , 8 , 9 ]. However, none of these studies have solely focused on bacteriologically confirmed PTB, and so, they may have included individuals without prior PTB, and this may not be a true definition of the post-PTB complications.…”