Retrospective study on the combined use of voriconazole and prednisolone in the treatment of acute allergic bronchopulmonary aspergillosis (ABPA)

Three years ago we started treating patients diagnosed with ABPA, an allergic lung disease provoked by Aspergillus fumigatus (Af), with a combined therapy of voriconazole and prednisolone. We used voriconazole at a dose of 200 mg twice a day for 4 months, while the initial prednisolone dose was 0.75 mg/kg/day for 1 month, then 0.25 mg/kg/day for 1 month, then progressive tapering (5 mg each fortnight) until the minimum dose of 5 mg/day, maintained until the fourth month. We evaluated patients at 6 months from the end of therapy. We enrolled 25 patients in the disease acute phase, who had never used azol therapy before, with a sudden asthmatic worsening. The patients' FEV1 value was 59% of predicted, total IgE were 1,687 IU/ml, blood eosinophils were 1,965 cell/ml, specific IgE for Af were 80 KU/L and IgG specific for Af were 2.70 KU/L. All patients had central bronchiectasis with dense mucus plugs. Results: There was a statistically significant reduction (p<0.0001) of total IgE values, of IgE specific for Af, of circulating eosinophils. FEV1, exhaled nitric oxide and Asthma Control Test improved in a statistically significant way (p<0.0001). No patient had a further re-exacerbation. The only parameter that didn't change was IgG specific for Af. In bronchoalveolar lavage fluid (BAL) we see a significant reduction in lymphocytes and eosinophils number (p<0.005). The Spearman correlation showed: a positive trend between eosinophil change in BAL and serum (r=0.6, p=0.07), BAL limphocytic and serum eosinophil change (r=0.68, p=0.04), similar to serum IgE change (r=0.8, p=0.008) and BAL and serum eosinophil baseline (r=0.55, p=0.005).