Snapshot A 14-year-old boy with past medical history of cystic fibrosis presents to his pulmonologist for a new cough. He reports that for the past few weeks, he has been coughing up brown sputum more and experiencing low-grade fevers. A recent chest radiograph showed a left lower lobe consolidation, and he completed a course of antibiotics without improvement. He also recently underwent testing for tuberculosis, which was all negative. On physical exam, there is wheezing and crackles bilaterally. A chest computed tomography (CT) shows central bronchiectasis and a skin test for Aspergillus causes a wheal 5 mm in diameter to form on his skin. Introduction Clinical definition hypersensitivity syndrome due to Aspergillus fumigatus, characterized by asthma, eosinophilia, recurrent pulmonary infiltrates, and bronchiectasis Epidemiology Demographics occurs in patients with pre-existing pulmonary disease more common in patients with cystic fibrosis Risk factors cystic fibrosis asthma ETIOLOGY Pathogenesis mechanism predominantly a type I hypersensitivity reaction Associated conditions atopic diseases atopic dermatitis allergic rhinitis asthma food allergies hyper IgE syndrome Presentation Symptoms systemic symptoms fatigue low-grade fevers chronic asthma refractory to medical therapy new or worsening cough brown/black sputum hemoptysis Physical exam dyspnea wheezing crackles imaging Chest radiograph often performed as the first imaging transient consolidations (fleeting shadows) finger-in-glove sign showing dilated bronchioles Chest computed tomography (CT) gold standard central bronchiectasis with normal peripheral bronchi finger-in-glove sign showing mucoid impaction in bronchioles Studies Diagnostic testing diagnostic approach Aspergillus skin test is used to screen for hypersensitivity, but further imaging and lab tests are recommended studies positive Aspergillus skin test (wheal) ↑ eosinophil and IgE levels Aspergillus-specific antibodies IgG and IgE precipitin antibodies Differential Tuberculosis distinguishing factor positive tuberculin skin test no peripheral eosinophilia DIAGNOSIS Diagnostic criteria multiple diagnostic criteria exist e.g., Rosenberg-Patterson diagnostic criteria for patients without cystic fibrosis: at least 6 must be met asthma, transient pulmonary opacities on imaging, positive Aspergillus skin testing, peripheral eosinophilia, positive Aspergillus-specific antibodies IgG or IgE, elevated peripheral IgE, bronchiectasis on imaging, or positive precipitin antibodies based on clinical presentation and imaging requires new findings on imaging that do not clear with antibiotics in patients with cystic fibrosis Treatment Management approach aimed at symptoms control and prevention of exacerbation First-line systemic corticosteroids Second-line itraconazole indication severe disease refractory to solo steroid therapy Other treatments omalizumab may reduce exacerbations Complications Respiratory failure Pulmonary hypertension Pneumothorax