Association between Allergic Bronchopulmonary Aspergillosis and Tuberculosis: A Systematic Review of 397 cases in literature

Abstract

Abstract Introduction: Although allergic bronchopulmonary aspergillosis (ABPA) is classically described in asthma and cystic fibrosis, tuberculosis (TB) with post-tubercular cavitary lung disease has recently been considered a probable predisposing factor for development of ABPA. While association of chronic pulmonary aspergillosis in patients with structural lung disease post TB has been well elucidated, the association with ABPA has not been reviewed systematically and the literature is quite scarce. Methods: We systematically screened the available literature from PubMed, Embase, SCOPUS and Web of Science databases for studies reporting association between ABPA and TB from 2010 to present using appropriate search terms, including the development of ABPA and Aspergillus sensitization in patients with previous or concomitant TB or post-tubercular structural lung disease (PTLD). Results: A total of 624 studies were identified from the initial search from the databases. After removal of duplicates (n = 213 results), 411 articles were chosen for review of abstracts. Out of these, 358 were removed after initial screening and eight were removed during final screening due to absence of adequate data on association of ABPA and TB. A total of 45 articles were included in the final systematic review of which, 21 were original articles and 24 were case reports. Four patterns of associations were described in a total of 397 patients: ABPA misdiagnosed as TB (51%), ABPA in patients with previous TB (22%), co-existent ABPA and TB (4%) and Aspergillus sensitization in patients with prior or active TB (23%). There was significant heterogeneity in terms of the criteria used for diagnosis of ABPA as well as in the diagnosis of pulmonary TB. The radiological patterns, treatment and outcomes were mostly reported for the overall population screened and not individually for patients who showed some form of ABPA-TB association. Central bronchiectasis (28%), mucoid-impaction/high-attenuation mucus/’glove and finger’ shadows (28%) and cavitary lesions (37%) were the most common radiographic abnormalities out of those whose individual radiological data could be extracted. Around 67% of the patients for whom treatment given were reported received steroids and/or antifungals. Adequate treatment response was reported for all the patients for whom it was reported. Conclusion: ABPA may be associated with TB in numerous ways. Misdiagnosis of ABPA as TB is the most common pattern followed by the patterns of Aspergillus sensitization /ABPA developing in patients with history of TB. The least common pattern was the that of concomitant TB and ABPA. On account of lack of uniformity in diagnosing ABPA and TB – future well designed studies are required to confirm these associations.