Severe asthma with fungal sensitisation (SAFS) in adults is associated with reduced lung function and increased morbidity [EurRespir J 2006;27:615–26, Am J RespirCare Med 2009; 179:11–18]. We hypothesised that fungal sensitisation in children with severe, therapy-resistant asthma (STRA) is associated with increased symptoms, medication use and airway inflammation, and reduced lung function.Methods
STRA was defined as before [Lancet 2010;376:814–25]. All children had been through a detailed assessment to optimise adherence and other aspects of basic management, as far as possible. We retrospectively evaluated 166 patients (median age at referral 11.7 years [4;17]; 61% males). SAFS (n=76) was defined as specific IgE (spIgE) or skin prick test (SPT) positivity to any of Aspergillus fumigatus, Alternaria alternata or Cladosporium herbarum. Non-sensitised patients (n=90) had negative spIgE and SPT to all fungal allergens tested. Age of onset, atopy, symptoms (asthma control test), medication usage, lung function and airway inflammation were assessed.Results
More boys had SAFS (57/76 (75%) vs 43/90 (48%), p<0.001). Children with SAFS had earlier onset of asthma (median 0.5 years [0;12.5] vs 1.5 [0;12.5], p=0.006), higher total serum IgE (637 IU/ml [12;6737] vs 177 [1;10 881], p=0.002) and higher sum of inhalant allergen SPT and spIgE [Allergy 2007;62:1379;86] (16 mm [0;38] vs 9 mm [0;36], p<0.001, and 78 IU/ml [0;400] vs 19 IU/ml [0;243], p=0.02, respectively). Children with SAFS had a lower FEV1 (1.4 L [0.5;3.8], vs 1.9 [0.7;4.3], p=0.008) and lower FVC (2.3 L [0.6;4] vs 2.6 [0.8;5.5], p=0.045). Bronchodilator reversibility was more frequent in SAFS (n=59/73 (81%) vs 42/81 (52%), p<0.001). Maintenance oral steroids were more frequently prescribed in SAFS (n=18/76(24%) vs 8/88 (9%), p=0.02). Symptoms and airway inflammation (assessed in sputum, bronchoalveolar lavage and endobronchial biopsy) were similar in children with and without fungal sensitisation.Conclusions
Children with STRA and fungal sensitisation had lower lung function, earlier asthma onset, more atopy and more bronchodilator responsiveness. There is a need for a randomised controlled trial of antifungal therapy in paediatric SAFS.