Infestations with helminths (cestodes,

nematodes and trematodes) are the commonest

causes of pulmonary eosinophilia in tropical countries

(1-3). Other causes of pulmonary eosinophilia

include Allergic Broncho-Pulmonary Aspergillosis

(ABPA) (4), chronic eosinophilic pneumonia (5),

cryptogenic pulmonary fibrosis (6), Wegener’s

granulomatosis (7), lymphomatoid granulomatosis

(8) eosinophilic granuloma of lung (9), the

Churg-Strauss syndrome (10), drug hypersensitivity

reactions (11) and infections such as brucellosis

(12), coccidioidomycosis (13), corynebacterium

pseudotuberculosis (14) and tuberculosis (15)

Vijayan, V K

NIRT Institutional Repository

145 HYPOTHESlS ALLERGIC BRONCHO-PULMONARY HELMINTHIASIS(ABPH)VIJAYAN VKCardio-Pulmonary Medicine Unit, Tuberculosis Research Centre,Indian Council of Medical Research Madras 600 031(Received original May 1991; revised October 1991)ABSTRACTBased on current literature, an aetiologicalclassification of pulmonary eosinophilia due tohelminths including tropical eosinophilia is proposed.IntroductionInfestations with helminths (cestodes,nematodes and trematodes) are the commonestcauses of pulmonary eosinophilia in tropical coun-tries (1-3). Other causes of pulmonary eosinophiliainclude Allergic Broncho-Pulmonary Aspergillosis(ABPA) (4), chronic eosinophilic pneumonia (5),cryptogenic pulmonary fibrosis(6), Wegener’sgranulomatosis (7), lymphomatoid granulomatosis(8) eosinophilic granuloma of lung (9), theChurg-Strauss syndrome (10), drug hypersensitivityreactions (11) and infections such as brucellosis(12), coccidioidomycosis (13), corynebacteriumpseudotuberculosis (14) and tuberculosis (15).Pulmonary eosinophilia due to helminths : One of the commonest forms of pulmonaryeosinophilia in tropical countriesis due to hy-persensitivity reaction to an occult form of filari-asis termed as tropical (filarial) eosinophilia (16)or Tropical Eosinophilia (TE) (17-20). TE presentswith symptoms suggestive of bronchial asthmasuch as cough, dyspnoea, nocturnal wheezingand chest discomfort, occassionally associatedwith such constitutional symptoms as weight loss,anorexia and fever (17,21). Physical examinationreveals rhonchi and rales (21). Chest radiographsshow a variety of abnormalities, including diffusemiliary mottling, pleural effusions,and uncom-monly cavitation and large areas of consolida-tion (22). High levels of blood and lung eosino-phils with elevated serum and lavage fluid levels ofIgE and filaria- specific IgE and IgG antibodies(17, 23, 24) had also been demonstrated. Pul-monary function studies had shownairway ob-struction in addition to reduced lung volumes andreduced diffusing capacity (21, 25-27). Following athree -week course of diethylcarbamazine (DEC),there was incomplete reversal of clinical, haema-tological, radiological and physiological changesone month after starting treatment (25). In conformitywith these findings,a chronic respiratory tract in-flammation as evidenced by a persistent eosino-philic alveolitis with lower respiratory tract inflam-matory cells spontaneously releasing exaggeratedamounts of 02 and H2O2 has also been demon-strated (28). It had also been shown that, at oneyear, patients with eosinophilic alveolitis had a sig-nificantly reduced diffusing capacity despite threeweeks treatment with DEC (21). It had also beenreported that bronchiectasis could occur during andpersist after clinical attacks of TE (29). Therefore,there is an urgent need to undertake controlledclinical trials in TE to assess the role of corticoster-oids in preventing the occurence of irreversibleradiological and lung function changes.A similar syndrome of pulmonary eosinophiliawith respiratory symptoms can result from infesta-tions with other helminths such as Ascaris (30),Ancylostoma species (31), Strongyloides ster-coralis (32) and Toxocara species (33, 34).Currently available immunological investigations ofantibody assays (35) may not differentiate the eo-sinophilic syndromes due to various helminthic in-fections because of antigenic similarities. Becauseof the probable broad-spectrum anti-helminthic ac-tion of DEC, patients with pulmonary eosinophiliadue to various helminthic infections respond totreatment with DEC (Personal observation). Thus itappears that the syndrome of tropical eosinophilia isan end result of a common pathogenesis resultingfrom infestations with various helminths. Thoughthe syndrome of Tropical eosinophilia is commonin tropical and sub-tropical countries, it had alsobeen described in subjects from temperate countrieson exposure to appropriate infections in endemicareas (36). Therefore,it will be ideal to have abetter name for this syndrome based on aetiologyand research should be directed to identify teststhat may differentiate various types of pulmonary146eosinophilia.Allergic broncho-pulmonary mycosis :A similar disease resulting from a hypersensi-tivity reaction to fungal antigens (Aspergillus spe-cies) has been termed Allergic Broncho-PulmonaryAspergillosis (ABPA)(4). ABPA also manifests asasthma with elevated serum levels of total IgEand specific antibodiesto aspergillus antigens (37).Pulmonary function tests had revealed both ob-structive and restrictive ventilatory defects (38). Ir-reversible lung changes including proximal bron-chiectasis can occur if ABPA is left untreated (39).Since other fungi such as Candida (40, 41),Helminthosporium (42), Stemphyllium (43) and Cur-valuria (44) can cause a similar syndrome, it wassuggested that the term “Allergic Broncho-Pulmo-nary Fungal diseases” was a better name for thedisease (45) (Table 1).TABLE 1Allergic Broncho-Pulmonary Mycoses (45)1. Allergic Broncho-Pulmonary Aspergillosis (4j.2. Allergic Broncho-Pulmonary Candidiasis (40).3. Allergic Broncho-Pulmonary Helminthosporiasis (42).4. Allergic Broncho-Putmonary Stemphyliosis (43).5. Allergic Broncho-Pulmonary Curvulariasis (44).Members in parenthesis refer to articles quoted in referenceComparison of ABPA and TE :Thus, there appears to be a similarity in pa-thogenesis of pulmonary eosinophilia resulting fromhypersensitivity reactions to fungi and helminths. Acomparison of two diseases viz. ABPA and TEwhich are prototypes of pulmonary eosinophilia dueto fungi and helminths are shown in Table 2.TABLE 2Comparison of ABPA and TEABPA TE1.2.3.4. 5.6.7.8.9.10.Can occurHelminthsDEC? CorticoteroidsLUNG INDIA (1991) IX, NO.4 (P.145-148)Both result from exaggerated immune-re-sponses to respective antigens as evidenced byelevated levels of total IgE and specific antibod-ies (17,35,37). Both have bronchial and lung par-enchymal abnormalities as revealed by similarpulmonary functionabnormalities (25,38). Thesemay be due to type I and type III hypersensitivityreactions. Lung eosinophils in both diseases cancause irreversible lung changes if left untreated(17,29,39). Therefore, it is suggested that the term“Allergic Broncho-Pulmonary Helminthiasis” is a bet-ter term, for pulmonary eosinophilia due tohelminthic infections. Terminologies that are appro-priate for pulmonary eosinophilia resulting fromvarious helminthic infections are given in Table 3.TABLE 3Allergic Broncho-Pulmonary HelminthiasisSuggested list of Infestations1. Allergic Broncho-Pulmonary Filariasis2. Allergic Broncho-Pulmonary Ascariasis3. Allergic Broncho-Pulmonary Ancylostomiasis4. Allergic Broncho-Pulmonary Strongyloidiasis5. Allergic Broncho-Pulmonary ToxocariasisTropical Eosinophilia can then be termed as “Aller-gic Broncho-Pulmonary Filariasis”.In case of an incorrect diagnosis in a patientwith pulmonary eosinophilia due to strongyloidi-asis and if this patient is treated with steroids, theparasite may become disseminated (46). This em-phasises the need for an aetiological diagnosisin patients with pulmonary eosinophilia.1.2.3.4.5.6.REFERENCESCrofton JW, Livingstone JL, Oswald NC and Roberts ATM :Pulmonary eosinophilia. Thorax, 1952; 7: 1-35.Spry CJF : Lung Diseases associated with eosinophils : In :Current perspectives in Al!ergy. 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Allergic broncho-pulmonary helmintyhiasis (ABPH)

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Allergic broncho-pulmonary helmintyhiasis (ABPH)

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