Exames para avaliar a sensibilização ao aspergillus fumigatus em fibrose cística / Tests to assess sensitization to aspergillus fumigatus in cystic fibrosis

RESUMO Objetivo: Avaliar os resultados dos exames utilizados para identificar a sensibilização IgE-mediada ao Aspergillus fumigatus em pacientes com fibrose cística. Métodos: Estudo transversal descritivo com amostra de conveniência de 86 pacientes com fibrose cística, acompanhados em Serviço de Referência de Fibrose Cística de hospital universitário terciário. Realizaram-se exames para avaliar sensibilização ao A. fumigatus em pacientes com fibrose cística: IgE sérica total, contagem de eosinófilos sanguíneos, identificação do fungo por swab de orofaringe ou por cultura de escarro, IgE sérica específica e testes cutâneos de hipersensibilidade imediata. Foram comparados os resultados dos diferentes exames realizados. Resultados: Em 33 (38,4%) pacientes com fibrose cística, com faixa etária de 1 a 33 anos (mediana de 8 anos), os resultados dos exames sobre sensibilização IgE mediada ao A. fumigatus foram: em 16 pacientes, aumento de IgE sérica específica (>0,35 kU/L); em 23, positividade aos testes cutâneos; e seis mostraram sensibilização a partir dos dois exames. Foram observados dois pacientes com eosinofilia (>1.000 eosinófilos/mm3) e sete com aumento de IgE sérica total (>1.000 UI/mL), sem que esses apresentassem positividade aos testes cutâneos ou aumento de IgE específica ao A. fumigatus. Em nenhum paciente foi isolado A. fumigatus no swab de orofaringe e/ou na cultura de escarro. Conclusões: Concluímos que, entre os exames para avaliar a sensibilização ao A. fumigatus na fibrose cística, são necessários os teste cutâneos de hipersensibilidade imediata e a dosagem de IgE sérica específica ao A. fumigatus. A eosinofilia sérica e a cultura de secreções respiratórias não foram essenciais neste estudo.

ABSTRACT Objective: To evaluate the results of the tests used to identify the IgE mediated sensitization to Aspergillus fumigatus in patients with cystic fibrosis. Methods: This is a cross-sectional descriptive study with a convenience sample of 86 patients diagnosed with cystic fibrosis in the Reference Service in Cystic Fibrosis at a tertiary teaching hospital. The following tests were performed to assess the sensitization to A. fumigatus in patients with cystic fibrosis: Total serum IgE, eosinophil count, fungus detection through oropharyngeal swab or sputum culture, serum-specific IgE, and immediate-type hypersensitivity (IgE) skin tests. We compared the results of the different tests performed. Results: In 33 (38.4%) patients with cystic fibrosis, with ages ranging from 1 to 33 years (median of 8 years), the IgE-mediated A. fumigatus sensitization test results were: in 16 patients, there was an increase in serum-specific IgE (>0.35 kU/L); in 23, skin tests were positive; and six had sensitization in both tests. We observed two patients with eosinophilia (>1,000 eosinophils/mm3) and seven with increasing total serum IgE (>1,000 IU/mL), all of whom obtained negative results in skin tests and had no IgE increase specific to A. fumigatus. A. fumigatus was not detected in oropharyngeal swabs and/or sputum culture of any patients. Conclusions: We conclude that, among the tests used to assess sensitization to A. fumigatus in cystic fibrosis patients, both serum-specific IgE and immediate-type hypersensitivity (IgE) skin tests are required. Serum eosinophilia and respiratory secretion culture were not essential in this study.

Effect of Aspergillus fumigatus sensitization and colonization on lung function and airways inflammation in asthma

The sensitization and exposure to fungal allergens have been reported to be associated with asthma. The importance of Aspergillus fumigatus [AF] sensitization and colonization of the airways in patients with asthma is unclear. To clarify the effect of sensitization and airways colonization of AF on lung function and airways inflammation in asthma. We studied 66 patients with asthma. Patients were classified into two groups according to AF sensitization: [1] AF-sensitized [immediate cutaneous reactivity >3 mm]; and [2] AFnonsensitized. A positive sputum culture for AF confirmed airways colonization by AF. Routine spirometry was performed for all patients. Airways inflammation was assessed by sputum differential inflammatory cell count. Asthma duration was significantly longer in AF-sensitized asthmatics. Significantly higher rates of positive AF-culture were detected in sputum from AF-sensitized asthmatics [63%] in comparison to AF-nonsensitized asthmatics [31%]. FEV1 and FEV1/FVC were more reduced in AF-sensitized asthmatics in comparison to AF-nonsensitized asthmatics. Sputum neutrophils count was significantly higher in AF-sensitized asthmatics in comparison to AF-nonsensitized asthmatics. Sputum eosinophils did not differ between AF-sensitized and AF-nonsensitized asthma groups, concordant with peripheral blood eosinophils, which did not differ significantly between groups. Multilinear regression analysis predicting FEV1% showed that AF sensitization and sputum neutrophil count were the most important predictors of FEV1 [p= 0.016 for both], followed by positive sputum culture for AF and sputum eosinophil count [p= 0.024 and 0.046 respectively]. [p = 0.105]. AF detection in sputum is associated with AF-sensitization, neutrophilic airway inflammation, and reduced lung function. This supports the concept that development of fixed airflow obstruction in asthma is consequent upon the damaging effects of airway colonization with AF

Aspergilloma formation in cavitary sarcoidosis / Formação de uma aspergilloma em sarcoidose com cavitação

Pulmonary cavitation is rather uncommon in patients with sarcoidosis, and aspergilloma is even more uncommon in such cases. Here, we present the case of a 63-year-old female patient with cavitary lung disease who had been under treatment for TB for 9 months. A diagnosis of pulmonary sarcoidosis was established based on the fiberoptic bronchoscopy finding of noncaseating granuloma. Treatment with corticosteroids led to a dramatic improvement in symptoms. While under treatment for sarcoidosis, the patient developed an aspergilloma. She presented immediate skin test reactivity to Aspergillus fumigatus, as well as positivity for A. fumigatus serum precipitins. This is the first reported case of aspergilloma formation in a patient with cavitary sarcoidosis in India.

A cavitação pulmonar é rara em pacientes com sarcoidose, e o aspergiloma é ainda mais raro nestes casos. Apresentamos o caso de uma paciente de 63 anos com doença pulmonar cavitária em tratamento para a TB por 9 meses. Estabeleceu-se o diagnóstico de sarcoidose pulmonar com base nos achados de granuloma não-caseoso na fibrobroncoscopia. Houve grande melhora dos sintomas com o tratamento com corticosteroides. A paciente desenvolveu um aspergiloma durante o tratamento para a sarcoidose. Houve reação imediata ao teste cutâneo para Aspergillus fumigatus, assim como resultado positivo para precipitinas de A. fumigatus no soro. Este é o primeiro caso relatado de formação de aspergiloma em um paciente com sarcoidose com cavitação na Índia.

Prevalência de aspergilose broncopulmonar alérgica em pacientes com fibrose cística na Bahia, Brasil / Prevalence of allergic bronchopulmonary aspergillosis in patients with cystic fibrosis in the state of Bahia, Brazil

OBJETIVO: Determinar a prevalência de aspergilose broncopulmonar alérgica (ABPA) em pacientes com fibrose cística acompanhados em um centro de referência da Bahia. MÉTODOS: Estudo transversal, com coleta prospectiva de dados, realizado no Centro de Referência de Fibrose Cística da Bahia do Hospital Especializado Octavio Mangabeira. Foram incluídos no estudo 74 pacientes que tinham diagnóstico de fibrose cística, com idade acima de 6 anos e tratados entre 9 de dezembro de 2003 e 7 de março de 2005. Foram analisadas as seguintes variáveis: gênero, idade, capacidade vital forçada, volume expiratório forçado no primeiro segundo, resposta a prova farmacodinâmica, achados em radiografia torácica e de seios de face, presença de sibilância, culturas para Aspergillus spp., imunoglobulina E (IgE) total, IgE específica para Aspergillus fumigatus e teste cutâneo de leitura imediata para aspergilina. RESULTADOS: Dos 74 pacientes, 2 foram diagnosticados com ABPA. Níveis de IgE total > 1.000 UI/mL foram observados em 17 pacientes (23%), teste cutâneo de leitura imediata para A. fumigatus positivos em 19 (25,7%) e sibilância em 60 (81,1%). CONCLUSÕES: A taxa de prevalência de ABPA foi de 2,7%. As altas taxas de IgE total, de teste cutâneo imediato para A. fumigatus positivos e de sibilância sugerem que estes pacientes devam ser acompanhados cuidadosamente por haver a possibilidade do desenvolvimento de ABPA.

OBJECTIVE: To determine the prevalence of allergic bronchopulmonary aspergillosis (ABPA) in patients with cystic fibrosis treated at a referral center in the state of Bahia, Brazil. METHODS: A cross-sectional study, with prospective data collection, carried out at the Cystic Fibrosis Referral Center of Bahia of the Octavio Mangabeira Specialized Hospital. We evaluated 74 patients diagnosed with cystic fibrosis, older than six years of age, treated between December 9, 2003 and March 7, 2005. We analyzed the following variables: gender, age, forced vital capacity, forced expiratory volume in one second, pharmacodynamic response, chest X-ray findings, facial sinus X-ray findings, wheezing, cultures for Aspergillus spp., total immunoglobulin E (IgE), specific IgE for Aspergillus fumigatus and immediate skin test reactivity to A.fumigatus antigen. RESULTS: Of the 74 patients, 2 were diagnosed with ABPA. We found total IgE levels > 1,000 IU/mL in 17 (23%), positive immediate skin reactivity to A. fumigatus antigen in 19 (25.7%) and wheezing in 60 (81.1%). CONCLUSIONS: The prevalence of ABPA was 2.7%. The high levels of total IgE, high incidence of wheezing and high rate of immediate skin test reactivity to A. fumigatus antigen suggest that these patients should be carefully monitored due to their propensity to develop ABPA.

Aspergilose broncopulmonar alérgica com imagem radiológica em "dedo de luva" / Allergic bronchopulmonary aspergillosis presenting a glove-finger shadow in radiographic images

A aspergilose broncopulmonar alérgica é uma doença pulmonar que ocorre em pacientes com asma ou fibrose cística, desencadeada pela reação de hipersensibilidade à presença do fungo Aspergilus fumigatus nas vias aéreas. Relatamos aqui um caso em que uma paciente com quadro clínico sugestivo de asma apresentou critérios clínicos, laboratoriais e radiológicos compatíveis com o diagnóstico de aspergilose broncopulmonar alérgica. A importância de tais achados deve-se ao fato de que quanto mais precocemente for feito o diagnóstico, menores serão os riscos de agravamento do quadro respiratório e de aparecimento de fibrose.

Allergic bronchopulmonary aspergillosis is a lung disease occurring in patients with asthma or cystic fibrosis, triggered by a hypersensitivity reaction to the presence of Aspergillus fumigatus in the airways. We report herein the case of a patient presenting a clinical profile suggestive of asthma and meeting the clinical, laboratory testing and radiological criteria for a diagnosis of allergic bronchopulmonary aspergillosis. The importance of such findings is that early diagnosis can reduce the risk of respiratory exacerbations and fibrosis.

Diagnóstico de ABPA em pacientes portadores de fibrose cística: utilidade clínica da pesquisa de IgE específica contra alérgenos recombinantes do Aspergillus fumigatus / ABPA diagnosis in cystic fibrosis patients: the clinical utility of IgE specific to recombinant Aspergillus fumigatus allergens

OBJETIVO: A aspergilose broncopulmonar alérgica (ABPA) é um fator complicador da fibrose cística que pode determinar uma combinação devastadora na evolução da doença pulmonar. A sobreposição de sinais e sintomas das duas enfermidades dificulta o diagnóstico, mesmo aplicando critérios padronizados. O objetivo deste trabalho foi identificar, em grupo de portadores de fibrose cística, os casos de ABPA através da detecção de IgE específica contra os alérgenos recombinantes do Aspergillus fumigatus e confrontar esse método com os critérios preconizados pela Cystic Fibrosis Foundation. MÉTODOS: Cinqüenta e quatro pacientes de 2 a 20 anos, com características que poderiam estar isoladamente presentes na ABPA, foram avaliados sistematicamente, incluindo: dados clínicos, tomografia computadorizada de tórax, teste cutâneo de hipersensibilidade imediata para A. fumigatus; dosagem de IgE sérica total, RAST para A. fumigatus, e IgE sérica específica para alérgenos recombinantes r Asp f1, f2, f3, f4 e f6. RESULTADOS: Foram elegíveis para o estudo 39 pacientes. Destes, 32 foram investigados. Houve sensibilização ao A. fumigatus em 34 por cento. Ambos os métodos, o critério da Cystic Fibrosis Foundation e a pesquisa de IgE específica contra antígenos recombinantes, determinaram três casos de ABPA; entretanto, o diagnóstico foi concordante em apenas dois pacientes. CONCLUSÃO: A detecção de IgE específica contra antígenos recombinantes do A. fumigatus foi ferramenta útil para detecção precoce da sensibilização e diagnóstico de ABPA. No entanto, a confirmação diagnóstica não pôde ser desvinculada da condição clínica, e sua utilização para diagnóstico, detecção de recidivas e critério de cura ainda requer estudos longitudinais, envolvendo maior número de pacientes.

Prevalence of aspergillosis in bronchogenic carcinoma.

Bronchoalveolar lavage of 42 patients of bronchogenic carcinoma was studied to find out the prevalence of aspergillosis. Sera of the patients were also analysed for presence of anti-Aspergillus antibodies by Immunodiffusion (ID), Enzyme linked immunosorbent assay (ELISA) and dot blot assay (DBA). Aspergillus was isolated in culture from 6 (14.2%) patients of bronchogenic carcinoma. Aspergillus fumigatus was the predominant species isolated. All the strains of Aspergillus were sensitive to itraconazole, ketoconazole and amphotericin B while resistance (33.3%) was found with fluconazole. Anti-aspergillus antibodies were detected equally by ID, ELISA and DBA in 9 (21.4%) cases. The present study revealed prevalence and seroprevalance of Aspergillus in bronchogenic carcinoma to be 14.2% and 21.4% respectively. Consistent reactivity against 18 kDa Aspergillus fumigatus antigen was noted in serologically positive cases. Antibodies against 18 kDa protein antigen in western blotting may be used as a reference marker for diagnosis of aspergillosis in bronchogenic carcinoma. It is also suggested that the simplest serological technique like ID may be performed along with culture for diagnosing Aspergillosis in patients of bronchogenic carcinoma since ID, ELISA and DBA showed similar sensitivity.

Molecular characterization of aspergillus fumigatus allergens.

Aspergillus fumigatus (Af) is ubiquitous saprophytic fungus associated with a broad spectrum of diseases in humans. These diseases range from benign colonization of the lung to life threatening diseases such as allergic bronchopulmonary aspergillosis (ABPA) and invasive aspergillosis. Af is the etiologic agent identified in most of the Aspergillus related human diseases and is therefore of particular clinical importance. Af induced obstructive airway diseases may be due to transient exposure to fungal spores resulting in a T helper 2 response. The IgE mediated inflammatory reaction could be due to colonization of bronchial airway epithelium by Af. Early and precise diagnosis of Aspergillus induced respiratory allergy is essential for preventing irreversible lung damages. The major problems in the diagnosis of A. fumigatus induced diseases are due to the lack of standardized and well characterized fungal extracts. The advent of molecular cloning technology and the development of phage surface display technology for cloning genes have facilitated the isolation of more relevant recombinant allergens. Using these techniques, a panel of different Af allergens having distinct IgE binding with various groups of Af sensitized patients have been cloned and characterized. These allergens can be categorized functionally as secreted and cytoplasmic proteins. The distinct IgE binding property of these purified and well characterized recombinant Af allergens may be useful for the differential diagnosis of Af related pulmonary complications.

Immunology of allergic bronchopulmonary aspergillosis.

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity lung disease caused predominantly by the ubiquitous fungus Aspergillus fumigatus. ABPA is characterized by eosinophilia, fleeting pulmonary infiltrates, central bronchiectasis, elevated serum IgE and Aspergillus specific IgG and IgE. The pathogenetic mechanism implicated in ABPA is not completely understood. The cytokine response detected in ABPA patients is of a CD4+ Th2 type as evidenced by the production of IL-4, IL-5, and very little or no IFN-g on stimulation of T-lymphocytes with Aspergillus antigens. Animal model studies using wild type and gene knockout mice indicate a more precise mechanism of lung injury in antigen exposed animals. IL-4 knockout mice invariably showed a predominant Th1 response. B-cell deficient and IgE knockout mice exposed to A. fumigatus antigens showed airway response similar to wild type mice indicating a lesser role for IgE and other antibodies in the pathogenesis of murine experimental ABPA. RAG negative mice failed to show airway hyperreactivity response, although airway hyperreactivity was induced in naive RAG negative animals when T-cells from wild type Aspergillus immunized mice were transferred. The results of these studies indicate a multi-factorial immunopathogenesis in ABPA, which include T-cells, IgE, eosinophils, mast cells, and various cytokines and chemokines.

Producción de antisueros fúngicos específicos en conejo / Specific fungi antisera production in rabbits

Se probó un método de inoculación en conejos, por vía intradérmica para la producción de antisueros fúngicos contra Aspergillus fumigatus (AF), Histoplasma capsulatum (HC), Paracoccidioides brasiliensis (PB) y Coccidioides immitis (CI), con el fin de ser utilizados como sueros control positivos para pruebas de inmunodifusión en gel de agar (ID). En este trabajo se utilizó como inmunógeno el antígeno en la dilución de uso (DU) para las pruebas de rutina de ID, lo que facilitó su estandarización. Los antígenos de AF, HC, CI se prepararon por los métodos descriptos por el Center for Disease Control (CDC), y el de PB según la técnica descripta por Camargo y col. Todos los conejos produjeron anticuerpos contra los diferentes antígenos específicos (bandas por ID) en el momento en que se alcanzaron los picos de respuesta primaria y luego de cada refuerzo. La respuesta secundaria fue igual o menor que la primaria, aunque se mantuvo la calidad y cantidad de bandas de precipitación específicas detectadas por ID. La inmunización primaria con concentraciones de antígeno mayores o menores a la DU, sólo analizadas en el caso de A. fumigatus, produjo bandas de precipitación menos definidas o en menor número respectivamente, aunque los títulos de anticuerpos fueron similares

Aspergilosis broncopulmonar: consideraciones sobre 122 casos con serología positiva para Aspergillus fumigatus / Bronchopulmonar aspergillosis: 122 cases diagnosed by serological tests for A. fumigatus

Se presenta el análisis de 122 casos de aspergilosis broncopulmonar diagnosticados entre los años 1990 y 1994, en el Departamento de Micología del Instituto Nacional de Higiene y Medicina Tropical de Guayaquil. Todos ellos presentaban anticuerpos frente al antígeno de A. fumigatus demostrables por inmunodifusión por la técnica de Ouchterlony. El estudio micológico en muestras de esputo fue realizado en 60 enfermos. Se señalan los parámetros considerados para el diagnóstico, las lesiones radiológicas observadas y los tratamientos instituídos

Extracción y caracterización de antígeno micelial de Aspergillus fumigatus / Antigen characterization of a mycelial extract of Aspergillus fumigatus

Este estudio presenta la estandarización y caracterización antigénica de un extracto micelial de Aspergillus fumigatus, con el fin de utilizarlo posteriormente en pruebas diagnósticas de aspergilosis pulmonar. Para la evaluación del antígeno micelial, se emplearon técnicas de doble inmunodifusión (DD), contrainmunoelectroforesis (CIE+ID) y enzimoinmunoensayo (ELISA), comparando sus resultados con un antígeno de referencia. La concentración de proteínas y carbohidratos del antígeno estudiado fue de 8.800 µg/mL y 2.452 µg/mL respectivamente, muy similares a los encontrados en el antígeno de referencia. Los antígenos analizados presentaron bandas de identidad total y parcial en la DD. No hubo bandas de precipitinas al enfrentar ambos antígenos con 20 sueros negativos, utilizando las pruebas de DD y CIE + ID. En la CIE+ID se presentaron precipitinas en los lados anódico y catódico de ambos antígenos. El punto de corte determinado en la prueba de Elisa para el antígeno del estudio fué de 0,352, con un intervalo de confianza del 95 por ciento. Es posible concluir que el antígeno micelial estudiado puede ser empleado en pruebas serológicas diagnósticas

Evaluation of clinico-immunological parameters in pediatric ABPA patients.

Allergic bronchopulmonary aspergillosis patients (ten in the age group 5-13) were studied with respect to clinical and immunodiagnostic tests. All the patients showed wheal and flare reaction with A. fumigatus antigens. Clinical features included bilateral infiltration and hilar lymphadenopathy. Eosinophilic count in these patients was observed to be in the range of 300-2500/mm3. Sera of six patients indicated precipitin reaction with A. fumigatus antigens. An elevated total serum IgE was noticed in all the patients. A. fumigatus specific IgG and IgE antibodies were increased in these patients. Optical density of the sera of all the patients against controls were observed to be in the range of (0.426 to 1.8 for IgG and 0.147 to 0.562 for IgE) by ELISA. Western blot analysis indicated that there may be correlation between the clinical stages of the disease and immunological reactivity of the sera with various antigenic components.

Fractionation of culture filtrate antigens of Aspergillus fumigatus.

Polyacrylamide disc gel electrophoresis (PAGE) and two-dimensional crossed immunoelectrophoresis (2D-CIE) of crude culture filtrate antigens prepared from three clinical isolates of Aspergillus fumigatus revealed a striking similarity in the number and nature of their antigenic components, notwithstanding the wide differences in their total protein contents. The antigenic components, which are largely proteins and glycoproteins, varied from 9-10 in number depending on the isolate. A prominent glycoprotein band, common to all the three isolates, merits further purification and detailed study. The serodiagnostic value of culture filtrate antigens of A. fumigatus vis-a-vis mycelial antigens, has been discussed.

Identification and partial characterization of diagnostically relevant antigens of Aspergillus fumigatus.

Metabolic antigens of Aspergillus fumigatus, soil strain 2605 and sputum isolate, were evaluated for their diagnostic applicability using hyperimmune sera and sera of adults and pediatric patients of allergic bronchopulmonary aspergillosis. An indirect ELISA was standardised by using 2-10 micrograms/ml of coating antigen for detection of specific IgG and IgE antibodies in the sera of patients. The ratios of absorbance for specific IgE and IgG antibodies by ELISA (normal to patients) were observed to be in the range of 1:2 to 1:3 to 1:8 respectively. These antigenic preparations were further analyzed to identify and characterize the individual components by immunoblotting. This analysis indicated the presence of allergenic and antigenic determinants in the antigens of molecular weights 70, 34, and 28 Kd. The utility of the antigens of soil strain for diagnostic purpose is suggested.

Aspergillus fumigatus fungus ball in hospitalized patients with chronic pulmonary disease: usefulness of double immunodiffusion test as a screening procedure

Trezentos e cinquenta pacientes sintomáticos respiratórios admitidos no Hospial Raphael de Paula Souza, sem diagnóstico etiológico definitivo, foram triados pela técnica de imunodifusäo dupla (IDD) para aspergilose. Quando a IDD foi positiva, informaçöes adicionais como histórico e exames radiológicos foram requisitados e, quando possível, espécimes clínicos foram processados para exames micológicos e histopatológicos. Linhas de precipitaçäo específicas para o antígeno de A. fumigatus foram encontradas em 29(8,3%) dos 350 soros de pacientes testados. Dezenove (65,5% dos 29 pacientes cm sorologia positiva foram reconhecidos como tendo boa fúngica pelos achados radiológicos em dois ou por ambos em oito pacientes. Este estudo prospectivo de dois anos mostrou que aspergilose pulmonar é um problema considerável entre pacientes admitidos em um hospital para sintomáticos respiratórios, especialmente aqueles com cavidades pulmonares ou bronquiectasias

Anticuerpos contra Aspergillus fumigatus en asmáticos atópicos / Antibody against Aspergillus fumigatus in atopic asthamtics

La observación de pruebas cutáneas inmediatas positivas a los extractos de Aspergillus fumigatus (Af.) en pacientes asmáticos atópicos libres de aspergiliosis broncopulmonar alérgica instó a estudiar más profundamente la dinámica inmunológica de estos pacientes en relación al antígeno mencionado. De cien asmáticos extrínsecos habitantes de Buenos Aires y sus alrededores con una IgE-PRIST basal promedio de 485,1 KU/L, 26 de ellos evidenciaron una prueba cutánea positiva a dicho alergeno preparado según técnicas convencionales. El RAST-IgE-anti-Af. fue positivo en 21 de esos 26 asmáticos. Por otro lado, las técnicas de inmunoprecipitación fueron negativas para los asmáticos y los controles; en estos últimos el RAST también fue negativo. Se destaca la importancia de la ausencia de precipitinas anti-Af. y la proclividad a practicar inmunoterapia con hongos anemófilos que incluyen al Af. en los atópicos portadores de alergia respiratoria. Se propone un seguimiento con técnicas específicas de inmunoprecipitación para detectar un efecto indeseable de dicha terapia con consecuencias imprevisibles