Allergic bronchopulmonary aspergillosis and Aspergillus-related airway diseases in bronchiectasis: a narrative review

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disorder classically associated with asthma or cystic fibrosis (CF). Recent guidelines have broadened the scope of ABPA to include patients with bronchiectasis, even without underlying asthma or CF. Beyond ABPA, other Aspergillus-associated phenotypes, namely Aspergillus sensitization (AS), chronic Aspergillus infection (CAI), and Aspergillus bronchitis, are increasingly recognized as clinically relevant entities in bronchiectasis. This review outlines the immunological, radiological, and clinical characteristics of ABPA in bronchiectasis, describes the prevalence and spectrum of Aspergillus-related airway disease, and presents a contemporary diagnostic and therapeutic framework based on the 2024 International Society for Human and Animal Mycology (ISHAM) ABPA Working Group (AWG) guidelines.

We searched PubMed since its inception to June 6, 2025. The keywords included "ABPA" OR "allergic bronchopulmonary aspergillosis" OR "bronchiectasis". Inclusion criteria focused on original studies in English involving bronchiectasis and ABPA, published in peer-reviewed journals.

ABPA, AS, and CAI represent a continuum of fungal airway disease shaped by host immune responses. ABPA affects approximately 4% of bronchiectasis patients and may be both a cause and consequence of bronchiectasis. AS and CAI collectively may affect up to 30% of bronchiectasis patients and are independently associated with worse clinical outcomes, including higher bronchiectasis severity scores and increased exacerbation rates. A. fumigatus-immunoglobulin E (IgE) remains the cornerstone of ABPA screening, with international guidelines advocating routine testing in all bronchiectasis patients at diagnosis. ABPA is diagnosed when AS coexists with supportive immunological and radiological features. Management includes systemic glucocorticoids or triazole antifungals, with inhaled antifungals and biologics reserved for treatment-dependent cases.

ABPA and related Aspergillus-associated endotypes are underrecognized yet modifiable drivers of disease progression in bronchiectasis. Routine screening for Aspergillus-related airway diseases and phenotype-specific management strategies are essential to improving patient outcomes.