Asthma and Allergic Bronchopulmonary Aspergillosis: Understanding, Insights, and State-of-the-Art

Allergic bronchopulmonary aspergillosis (ABPA) is a severe asthma endotype arising from dysregulated immune responses to Aspergillus fumigatus in susceptible individuals. ABPA is characterized by exaggerated type 2 immune responses, markedly elevated serum total IgE and A. fumigatus-specific IgE and IgG levels, peripheral blood eosinophilia, and imaging abnormalities, including bronchiectasis and mucus impaction. Genetic predisposition involving HLA genotypes and immune-related polymorphisms contributes to disease susceptibility. The 2024 International Society of Human and Animal Mycology guidelines provide standardized criteria that integrate clinical, immunological, and radiological parameters to identify ABPA and distinguish it from overlapping diagnoses. Management employs a dual approach: anti-inflammatory therapy with systemic corticosteroids targets dysregulated immunity, while antifungal therapy with triazoles reduces airway fungal burden. The relapsing-remitting disease course necessitates systematic monitoring using clinical assessment, total IgE levels, and serial imaging to detect relapses, distinguish them from asthma exacerbations or infections, and optimize treatment intensity. Despite substantial progress in understanding the pathobiology of ABPA, high-quality evidence for optimal management strategies remains limited. Future research should focus on precision medicine approaches, novel biomarkers, and inhaled antifungal therapies to improve outcomes in this severe asthma phenotype. This review provides clinicians with comprehensive information on the pathobiology, diagnosis, classification, and evidence-based management strategies for ABPA, aiming to improve outcomes for patients with this severe asthma endotype.