Aspergillosis

Aspergillosis is the name of a group of fungal conditions caused by a mould called aspergillus.

It usually affects the respiratory system (windpipe, sinuses and lungs) and causes wheezing and coughing, but it can spread to anywhere in the body.

Aspergillosis can usually be treated with medication, but in a few cases it's very serious and potentially life-threatening.

How do you get aspergillosis?

You can get aspergillosis if you inhale tiny particles of the aspergillus mould that hang in the air.

The mould is found in many different places, but it's particularly common in:

• rotting leaves and compost
• plants, trees and crops
• air conditioning and heating systems
• insulation material
• dust

In most people, inhaling aspergillus particles isn't a problem, because your immune system quickly destroys them. However, aspergillosis can develop if you have a pre-existing lung condition, such as asthma or cystic fibrosis, or if you have a weakened immune system.

Aspergillosis isn't contagious, so it can't be passed from person to person.

Aspergillosis is caused by breathing in small particles of a mould called aspergillus.

In most healthy people, the immune system is able to quickly destroy the mould before it causes any problems. However, symptoms can develop in people with a pre-existing lung condition or a weak immune system.

Aspergillosis isn't contagious, so it can't be passed from person to person.

Aspergillus mould

Aspergillus mould is found in all countries and in many different environments. This makes it difficult to avoid.

Aspergillus mould can be found in:

• rotting leaves and compost
• plants, trees and crops
• air conditioning and heating systems
• insulation material
• carpets
• pillows and bedding 
• dust
• ground pepper and spices

Who's most at risk?

Aspergillus can cause aspergillosis if you have a health problem affecting your lungs, or your immune system is weak.

You may be at risk of aspergillosis if you have:

• asthma – a common long-term condition that can cause coughing, wheezing, chest tightness and breathlessness
• cystic fibrosis – a condition in which the lungs and digestive system become clogged with thick, sticky mucus
• chronic obstructive pulmonary disease (COPD) – a group of lung conditions that affect breathing
• tuberculosis (TB) – a bacterial infection that mainly affects the lungs
• sarcoidosis – where small patches of swollen tissue develop in the lungs
• HIV or AIDS – conditions in which the immune system is weakened
• current or recent cancer treatment – including radiotherapy and chemotherapy
• an organ transplant – as you'll need to take medication that weakens your immune system

If you're at risk, you may need to take extra precautions to prevent aspergillosis – for example, by wearing a face mask near dusty environments, avoiding activities such as gardening, or taking long-term antifungal medication.

Symptoms of aspergillosis

The symptoms of aspergillosis vary.

General symptoms can include:

• shortness of breath
• a persistent cough
• coughing up mucus or coughing up blood
• fatigue
• weight loss
• a high temperature

Contact your doctor if you develop severe or persistent symptoms of aspergillosis, particularly if you have a weak immune system. There are several tests that can lead to a diagnosis.

The symptoms of aspergillosis vary, depending on the type and the part of the body that's affected.

Allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitisation

Symptoms of allergic bronchopulmonary aspergillosis (ABPA) can include:

• shortness of breath 
• wheezing
• fatigue
• a cough that brings up thick lumps of mucus
• generally feeling unwell

If you also have asthma, this may become more difficult to control with medication.

Symptoms of severe asthma with fungal sensitisation (SAFS) include:

• persistent wheezing 
• severe breathlessness
• a persistent blocked or runny nose

Chronic pulmonary aspergillosis and aspergilloma

In the early stages, chronic pulmonary aspergillosis (CPA) may not have any symptoms. Those that may develop later include:

• shortness of breath
• a persistent cough
• coughing up blood
• unintentional weight loss
• feeling very tired and run down

If a ball of fungus (aspergilloma) develops in the lungs, symptoms can include coughing up blood, a persistent cough, and a slightly raised temperature.

Invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis (IPA) affects the lungs at first, but can spread to other parts of the body such as the skin, eyes, brain and other internal organs.

Initial symptoms can include:

• a raised temperature (fever)
• coughing up blood
• shortness of breath
• chest pain or discomfort

Additional symptoms can develop as the infection spreads. For example, headaches and seizures can occur if the infection reaches the brain.

When to get medical advice

Always contact your GP if you:

• cough up blood
• have unexplained weight loss
• have a persistent cough and fever

If you develop symptoms of aspergillosis and have a weak immune system – for example, because of an organ transplant, cancer treatment or an underlying condition – contact your GP or specialist immediately.

Diagnoising

If it's possible that you have aspergillosis, a number of checks and tests can be carried out to confirm the diagnosis and identify the specific type.

Symptoms and medical history

It's important to describe exactly what symptoms you have, as the symptoms of aspergillosis can vary slightly between the different types.

For example, wheezing is more likely to be a symptom of allergic bronchopulmonary aspergillosis (ABPA) or severe asthma with fungal sensitisation (SAFS), while a long-term cough and unexplained weight loss are more likely to be caused by chronic pulmonary aspergillosis (CPA).

Your medical history will also be taken into account, as the different types of aspergillosis are associated with different underlying health problems.

ABPA and SAFS are closely associated with asthma or cystic fibrosis, whereas invasive pulmonary aspergillosis (IPA) occurs more often in people with weakened immune systems.

Allergy tests

If ABPA or SAFS is suspected, you'll usually have a skin prick test.

Your skin will be pricked with a needle that contains a small amount of aspergillus mould. If you're allergic, the area of skin where the needle was inserted will come up in a hard red bump.

Alternatively, your blood may be tested for aspergillus antibodies called IgE antibodies. These are produced by your immune system if you're allergic to the aspergillus mould.

Blood and mucus tests

If your symptoms are not thought to be caused by an allergy, you may have a blood test to check for different aspergillus antibodies called IgG antibodies.

These indicate that you've been infected with the aspergillus mould, such as in cases of CPA.

A sample of your mucus can also be tested to see if it contains the mould.

X-rays and scans

A chest X-ray can help determine if you have CPA, as it can show whether there are any clear spaces (cavities) or fungal balls (aspergillomas) in your lungs.

A computerised tomography (CT) scan is useful in helping to diagnose ABPA or SAFS, as it's more detailed and can show less obvious damage or mucus in the lungs. It can also detect damage caused by IPA.

Bronchoscopy and biopsy

In some cases, a procedure called a bronchoscopy may be carried out to allow your doctor to directly see inside your lungs and airways.

A bronchoscopy involves inserting a long, flexible tube with a camera at the end into your lungs, via your nose or mouth.

During a bronchoscopy, a small piece of affected tissue may be removed (known as a biopsy) to test it for aspergillus mould.

Types of aspergillosis

The main types of aspergillosis that affect the lungs are:

• allergic bronchopulmonary aspergillosis
• chronic pulmonary aspergillosis
• invasive pulmonary aspergillosis

Aspergillus mould can also sometimes infect other parts of the body, including the skin, eyes, sinuses and other internal organs, mainly in people with a weak immune system.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is caused by an allergy to inhaled aspergillus particles and typically causes wheezing, shortness of breath, a cough with mucus and sometimes blood. It's caused by the immune system reacting to the aspergillus mould.

ABPA usually affects people with asthma or cystic fibrosis. It's estimated that around 1 in every 40 people with asthma may be affected by ABPA.

There's also a very similar condition called severe asthma with fungal sensitisation (SAFS).

Chronic pulmonary aspergillosis

Chronic pulmonary aspergillosis (CPA) is a long-term infection that usually only affects people with an underlying lung condition, such as tuberculosis (TB), chronic obstructive pulmonary disorder (COPD) or sarcoidosis. Along with a persistent cough, breathlessness, tiredness and weight loss, coughing up blood is a common symptom.

CPA can sometimes cause an aspergilloma (a fungal ball) to grow in the lungs. It can also result in the lungs becoming permanently scarred if it isn't treated. 

It's estimated that around 400-750 people in England have CPA.

CPA requires specialist follow up treatment with antifungal medications and is usually long-term. The National Aspergillosis Centre offers specialist follow up of patients with CPA.

Invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis (IPA) usually only affects people with a weak immune system, such as people who have received a bone marrow transplant or cancer treatment, or those with HIV or AIDS. It's the most serious type of aspergillosis.

If you have IPA, it's likely you'll have a raised temperature as well as lung symptoms, such as a cough, chest pain or breathlessness.

In IPA, the aspergillus mould can spread through the bloodstream from the lungs to the brain, eyes, heart or kidneys. This is very serious and can be life-threatening if it's not treated quickly.

IPA is estimated to affect up to one in every four people who've had a bone marrow transplant, a heart or lung transplant, or high-dose chemotherapy for leukaemia (cancer of the blood cells).

Treatments for aspergillosis

Treatment for aspergillosis depends on the specific type.

ABPA and SAFS are usually treated with steroid medication to dampen the reaction of the immune system to the aspergillus particles, and antifungal medication to help kill the mould.

CPA and aspergilloma can be treated with long-term antifungal medication. In some cases, surgery may be needed to remove an aspergilloma from the lungs, prevent bleeding in the lungs, or remove infected tissue.

IPA is treated in hospital with powerful antifungal medications given by a drip into a vein. The infection can spread very quickly, and people who develop IPA are usually already very ill. This means that, unfortunately, around half of those with the condition die from it.

Treatment for aspergillosis varies, depending on the type you have and how severe it is.

Most cases are treated with medication, although occasionally surgery may be necessary.

Allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitisation

Allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS) are often treated using steroid medication and antifungal medication.

Measures to reduce your risk of further exposure to the aspergillus mould may also help. Read more about preventing aspergillosis.

Steroid medication for ABPA and SAFS

Steroid tablets suppress the immune system, which helps to prevent the allergic reaction associated with ABPA and SAFS.

Treatment is usually required for at least a few months, to help keep  symptoms under control.

However, taking steroids for a long time can lead to side effects such as weight gain, high blood pressure and osteoporosis. You'll need regular check-ups during treatment to check for these.

Antifungals for ABPA and SAFS

An antifungal medication called itraconazole is often used to treat ABPA and SAFS. It works by killing the aspergillus mould that causes these conditions.

If you have asthma, bear in mind that itraconazole can increase the effectiveness of some steroid treatments you may be using to control the condition. This means that, when steroids are stopped, it is possible that you may experience symptoms of steroid withdrawal (such as weight loss, muscle weakness and low blood pressure).

Some steroids are affected by itraconazole more than others, so make sure to check with your doctor. Even inhaled steroids used for asthma can be affected by itraconazole. You can read more about interactions between antifungals and other medicines on the Aspergillus & Aspergillosis Website.

Chronic pulmonary aspergillosis and aspergilloma

Chronic pulmonary aspergillosis (CPA) often requires long-term treatment with antifungal medication, but occasionally surgery may be necessary.

An aspergilloma (fungal ball in the lungs) doesn't always need to be treated, but sometimes antifungals may be prescribed or surgery may be carried out.

Antifungals for CPA

Itraconazole, voriconazole and posaconazole are the antifungals used to treat chronic pulmonary aspergillosis and aspergilloma.

Itraconazole is usually tried first, but if it’s ineffective or has troublesome side effects, voriconazole or posaconazole may be used instead. These medicines are usually taken as a liquid or tablets, although antifungal injections may be used if these don’t work.

How long you'll need to take these for will depend on how well your symptoms react to them. Some people will require lifelong treatment.

Itraconazole comes in tablet and liquid form. The tablets need to be taken with food, while the liquid needs to be taken on a empty stomach.

Common side effects of itraconazole include:

• headaches
• feeling sick
• liver problems
• ankle swelling
• abdominal (tummy) pain
• diarrhoea or constipation
• an itchy rash

Less common side effects can include peripheral neuropathy (tingling or numbness, usually in the feet or hands), hair loss, blurred or double vision, and tinnitus.

Like all antifungal medications, itraconazole can interact with other medications, so it’s important to let your doctor know if you're taking any other medicines. You can check the interactions between antifungals and other medicines on the Aspergillus & Aspergillosis Website.

Posaconazole also comes in liquid and tablet form. The liquid has to be taken with a fatty meal, while the tablet can be taken with or without food.

Possible side effects of posaconazole include feeling sick, liver problems and peripheral neuropathy. You can read about the side effects of voriconazole below.

Surgery for CPA

If you have CPA, surgery may be carried out to:

• remove an aspergilloma
• block some blood vessels in the lungs if you experience severe bleeding
• remove part of a lung or an entire infected lung if antifungals aren't helping

Many people who have surgery to remove a lung worry that they'll be unable to breathe properly afterwards, but it's possible to breathe normally with just one lung.

Invasive pulmonary aspergillosis

Treatment for invasive pulmonary aspergillosis (IPA) involves taking antifungal medication to tackle the infection and having treatment to boost your immune system.

In some cases, surgery may also be necessary.

Antifungals for IPA

Voriconazole is a powerful antifungal medication that's usually used to treat IPA. It can be given directly through a drip into a vein (intravenously) or as tablets.

If you're diagnosed with IPA, it's likely that you'll be admitted to hospital so that you can be carefully monitored while you're on voriconazole. You may be given assistance with your breathing if you need it.

Common side effects of voriconazole include:

• blurred vision or seeing colours (this is temporary and not dangerous)
• vivid dreams
• a rash on your skin that gets worse after exposure to the sun
• a high temperature (fever)
• diarrhoea
• breathing difficulties
• tingling or numbness in your feet or hands

Less common side effects include depression, anxiety, insomnia, fainting and a very fast or very slow heartbeat.

Boosting the immune system in people with IPA

Most people with IPA also have a weakened immune system, so will be given treatment to help strengthen it.

This may involve reducing the dose of any medication you're currently taking that weakens your immune system – such as anti-rejection (immunosuppressant) medication following an organ transplant.

Additional medication can also be given to temporarily boost your immune system, such as colony-stimulating factors (CSFs). CSFs encourage your bone marrow to produce more white blood cells, which help fight infection.

The most common side effects of CSFs include joint and muscle pain, headaches and nausea.

Surgery for IPA

In severe cases, where antifungal medications aren't helping and the infection has spread within the lungs or to other parts of the body, such as the skin, surgery may be needed to remove the infected areas.

Preventing aspergillosis

It's almost impossible to avoid the aspergillus mould completely, but there are precautions you can take to reduce your exposure if you're at risk of aspergillosis.

Try to avoid places where the mould is often found, such as:

• compost heaps
• grain stores
• rotting vegetation
• piles of dead leaves
• marshland and bogs
• forests

If you have a weakened immune system, you may also be advised to take extra precautions, such as wearing a face mask and taking a long-term course of antifungal medication.

It's virtually impossible to avoid the aspergillus mould completely, but there are some precautions you can take to reduce your risk of developing aspergillosis.

These precautions are particularly important if you're at a high risk of aspergillosis.

Avoiding exposure

The main way to prevent aspergillosis is to avoid being exposed to the aspergillus fungus as much as possible.

Try to avoid places where the aspergillus fungus is likely to be found, such as:

• compost heaps
• grain stores
• rotting vegetation
• piles of dead leaves
• marshland and bogs
• forests

In buildings, try to minimise your exposure to the fungus by reducing and containing dust as much as possible – particularly during construction work. Keep windows closed if there's a lot of dust or digging outside.

Extra precautions for those at high risk

If you're at a particularly high risk of severe aspergillosis – for example, because you have a weak immune system – your doctor may recommend extra precautions, such as:

• avoiding certain activities that involve close contact with soil and dust, such as gardening
• wearing a face mask when you're near dusty environments – be aware that aspergillus particles are very small and not all face masks will filter them out; the Support for People with Aspergillosis website has more information about suitable face masks
• using air purifiers – this requires bulky and expensive equipment to be effective, although there are purifiers that can be used at home
• drying wet washing outdoors, in a tumble dryer or in a well ventilated indoor space away from bedrooms and living areas

Some people at risk will be given a course of antifungal medication to help prevent fungal infections.