Stepwise, precision-based management of allergic Bronchopulmonary Aspergillosis/Mycosis: A real-life multicenter...

Allergic bronchopulmonary aspergillosis (ABPA) and allergic bronchopulmonary mycosis (ABPM) are hypersensitivity disorders characterized by fungal colonization of the airways and exaggerated Th2-mediated immune responses. Despite corticosteroids being the cornerstone of treatment, adverse effects, relapses, and steroid dependence necessitate adjunctive antifungal and biologic therapies. This study aimed to evaluate clinical, functional, and immunologic responses to different treatment combinations in patients with ABPA or ABPM.

This retrospective, multicenter, cross-sectional study included 70 patients diagnosed with ABPA (n = 54) or ABPM (n = 16) at two tertiary chest disease centers between 2016 and 2023. Patients were grouped according to systemic corticosteroid (SS) use (SS-using vs non-SS) and further subdivided based on treatment composition (antifungal ± biologic therapy vs antifungal alone). Changes in FEV₁ (Forced Expiratory Volume in 1 second), Asthma Control Test (ACT) scores, total serum IgE, and peripheral blood eosinophil count (PBEC) before and after treatment were analyzed.

In the SS-using group, combination therapy with antifungal ± biologic agents produced significant improvements in FEV₁ (mL and %) and ACT scores, along with substantial reductions in total IgE and PBEC levels (all P < 0.05). Antifungal monotherapy yielded significant reductions in immunologic parameters but no functional improvement. In the non-SS group, changes were minimal across most parameters, except for a modest reduction in total IgE within the antifungal ± biologic subgroup. The most comprehensive clinical and immunologic responses were observed in patients treated with corticosteroids combined with antifungal and biologic therapy.

SS remain the primary therapeutic modality for ABPA, but the addition of antifungal and biologic agents enhances both immunologic and functional recovery. A precision-based, stepwise treatment model-initiating with corticosteroids, followed by antifungal therapy, and incorporating targeted biologics-may optimize long-term outcomes, minimize steroid exposure, and promote sustained remission in ABPA and ABPM.