Dr Livingstone Chishimba is a specialist aspergillosis doctor working at the National Aspergillosis Centre, Manchester, UK. This is the second session he has run discussing & answering questions from our patients and those who are members of our support groups online http://uk.groups.yahoo.com/group/AspergillusSupport/

1. Support Meeting for
Aspergillosis Patients
LED BY GRAHAM ATHERTON
SUPPORTED BY
MARIE KIRWAN, GEORGINA POWELL & DEBBIE KENNEDY
NAC CENTRE MANAGER CHRIS HARRIS
QUESTIONS & ANSWERS, LIVINGSTONE CHISHIMBA (ASPERGILLOSIS DOCTOR)
NATIONAL ASPERGILLOSIS CENTRE
UHSM
MANCHESTER
Fungal Research Trust

2. Programme
 1pm Introduction & future
 1:30 Livingstone Chishimba
 2:30 Tea & Coffee
 3:00 Close

3. Quick Contact
 Last week showed the need for me to be able to contact
people who hope to attend via a reliable direct method –
newsletters and contact via online groups didn’t work
 Give me your mobile numbers and I can text everyone
easily – instant and up to date

4. Local Patients Support Group
 London meeting was blighted by illness but have an interest
group of 9 to support future efforts
 1 patients attended
 Identified Brompton Hospital as a ‘target’ for support*
 Identified a specialist nurse to help out by attending
 www.facebook.com/groups/ALSGLondon/
*Brompton now agreed to display information about support
group

5. Awareness
Facebook
80 members so far (69 friends)
Several ‘pages’
 Aspergillosis Support:
www.facebook.com/groups/aspergillussupport/
 Local groups:
 Liverpool: www.facebook.com/groups/ALSGLiverpool/
 West Midlands: www.facebook.com/groups/ALSGWestMidlands/
 London: www.facebook.com/groups/ALSGLondon/

7. Awareness
 Mouldy buildings
 Writing guidelines
 Facebook page (awareness)
 Awareness campaigns
 www.facebook.com/groups/363940156983477/
 Revised patients notes
www.aspergillus.org.uk/newpatients/dampbuilding.php

8. Student competitions
Aim: Building awareness amongst younger people & parents
 Art & music
 Original compositions
 £1200 prize (school & individual share)
 Theme is ‘funky fungi’
 UPDATE: 3-400 entries – will be judged over the summer
 www. projectlifecompetition.org

9. eBooks written by Patients
2 now available – both via download from Amazon
(www.amazon.co.uk)
The Lady with the Aspergillus (£1.94 all
Proceeds to Fungal Research Trust)
by Julie Michael
A Fly on the Ward (£1.94) by
Michael Chapman

10. Aspergillosis Study Day
 For all professions allied to medicine – nurses,
physio’s to improve knowledge & awareness
 70 people attended full day course organised by
Goergina – seemed very successful
 Feedback analysed?? Georgina…
 Hope to repeat?...

11. Next Meeting (June)
 Centre Manager (Chris Harris) & Specialist Nurse
(Deb Kennedy) will talk about the new home service
available to some of our patients – who we can offer
this to, how it will be delivered.

12. Thank You
“The best chance we have of beating this illness is to
work together”
Living with it, Working with it, Treating it
Fungal Research Trust

13. Patient meeting
-Q &A
Dr Livingstone Chishimba
University Hospital of South
Manchester

14. Patient doctor

15. Doctor Patient

18. Q4
• Does climate make any difference?

19. Helpful fungi:
• Most of us use fungi every day without knowing it.
• We eat mushrooms and Quorn (a vegetarian fungal protein), but we also prepare many other foods
using fungi.
• The yeast Saccharomyces cerevisiae is used to ferment sugar to alcohol and carbon dioxide – the
process used to make beer and wine and also to make bread rise.
• The fungi Aspergillus oryzae and Aspergillus sojae are used in the production of the oriental foods
soy sauce and miso.
• We also use fungi to produce flavourings, vitamins and enzymes and to mature many cheeses.
• Fungi play an essential role in both the Nitrogen and Carbon cycle by breaking down dead organic
material.

20. Helpful fungi:
• We get some important drugs from fungi such as the
antibiotic penicillin and cyclosporin A - a drug that stops
organ rejection after transplantation.
• Research scientists use several fungi to investigate basic
functions that occur in all cells because they are simple and
easy to grow; some cancer research is done using fungi.
• Fungi are responsible for breaking down dead organic
matter which allows nutrients to be cycled through the
ecosystem.

21. Importance of fungi:
• Without fungi we would not have
• bread, beer, wine or antibiotics, but more importantly without
the nutrient recycling and plant nutrition provided by fungi -
we probably could not survive at all.

22. The life cycle of Aspergillus
Spores inhaled Germination
Mass of hyphae Hyphal elongation
(plateau phase) and branching

23. Hospital demolition
Hansen et al. JHI 2008; 70: 259-264.

24. Source of Aspergillus

25. Exposure in the garden

26. Heavy excavation!
Nihtinen et al. 2007 BMT

27. Allergy Aspergillosis
* acute allergic reaction (bronchospasm, …)
* allergic sinusitis
* allergic bronchopulmonary aspergillose (ABPA)
•Asthmatic bronchitis

28. ABPA and severe asthma
www.emphysema-copd.co.uk

29. Chronic Pulmonary Aspergillosis (CPA)
Underlying diseases
• Classical tuberculosis * ~20%
• Atypical tuberculosis *
• Allergic bronchopulmonary aspergillosis *
• Lung cancer survivor *
• Pneumothorax *
• COPD/emphysema *
• Sarcoidosis (stage II/III) *
• Rheumatoid arthritis
• Thoracic surgery
• Asthma
• Chest radiotherapy
• None
* Common
Smith, ISHAM 2009

30. Chronic pulmonary aspergillosis
www.aspergillus.org.uk

31. Chronic cavitary aspergillosis in a patient with old TBC

32. Aspergilloma

33. Aspergillosis
3/ Invasive
* invasive pulmonary aspergillosis
* tracheobronchitis
* sinusitis
* cerebral aspergillosis
* skin aspergillosis
* osteomyelitis (bones)

34. FUNGAL KERATITIS

37. Treatment
• Treat or not to treat?-
– Various consideration
– Risk benefit ratio
• Antifungals
• Surgical
• Rx complications
– keratitis
• Symptomatic Rx
– haemoptysis
• Rx underlying disease
• Environmental control

38. Patient doctor

39. Patient meeting
-Q &A

40. Frequency, dose, duration of
itraconazole
• It seems that some people on the aspergillus
site are using Sporanox every day/year as in
order to prevent eruption of ABPA.
• Some claims 200mg/day. Any experience with
this situation?

41. Frequency, dose, duration of
itraconazole
• Indication in ABPA is treatment and not
prevention
• Not to be used for prevention if no disease
even if
– Family history or exposure to moulds
• May be needed in those with relapses even
without symptoms.

42. Some claim 200mg/day. Any experience
with this situation?
• BD, od
• 100-200mg/day/BD depending on
• Wt, tolerability & ability to metabolise meds

43. Q2a. Does the mould clear from my lungs in the
summer months and grows again once the damp
weather starts?
• Not necessarily but increased exposure to
mould may occur during damp weather.
• Damp weather may also be associated with
worsening of underlying/associated
conditions
– Asthma
– COPD
– bronchiectasis

45. Q2b
• Why do I always have a croaky throat and feel
like there is 'gunk' sitting in my throat just
'stuck' there?
• Is that from medication or to do with the
fungus?

46. Q2b: croaky throat & feeling of 'gunk'
sitting in my throat
• Croaky throat may arise from various factors:
fungal or non-fungal
– Throat inflammation
– Sputum
– Secretions
– Viral infections
– Underlying/co-existing disease
• Not necessary from medications.
• If concerned speak to your GP

48. Should I be on anti-fungal medicine (the
registrar said not) or is this only for severe
cases?
• Treat or not to treat?
– Various consideration
– Risk benefit ratio
– Definitive diagnosis ( not doubt).
– Previous experience with anti-fungals

49. Objective of treatment
• Reduce symptoms
• improve QOL,
• improve lung faction,
• prevent or reduce disease decline.
– Stable or assymptomatic cases do not warrant
treatment.
– Anti-fungals like other drugs have side effects.
– Benefit should outweigh risk
• Definitive diagnosis ( not doubt).

50. Q2c
• I have read a few things on forums where people feel
they were misdiagnosed with pneumonia when it
was actually the mould - wondering if this is the case
with me?

51. Different diseases as pneumonia
• Fungal disease
• Cancer
• Fluid
• Lymphoma
• Systemic dieases: WG, MPA etc
• But
– Pneumonia is the commonest and usually first thought
– Doctors will always consider differential diagnosis
– Other diagnosis may not be straight foward
– Contact your doctor or alternative medical advice if concerned.

52. ABPA as non-resolving pneumonia
Chishimba L , Journal of asthma, March 2002

53. Mould as cancer
Chishimba L , Journal of asthma, March 2002

54. Q2d. Do steroids/antibiotics cause mould
to grow more?
• Neither steroids nor antibiotics cause mould
to grow but excessive steroids
– Suppress body immunity and predispose to fungal
colonisation, spread and complications
• IA
• ↑Frequency of infection
• Candiasis: oral or genital etc
• Aspergilloma in COPD patients (ICS)- Dr Wouter
Meersseman, Belgium grp, ERS 2011, Amsterdam.

55. Are there things that I can eat/drink to help myself or
anything that can make things worse?
• Only balanced nutritious diet important for
your body.
• Avoid none nutritious food.
• Always avoid alcohol.

56. Q3
• What is the current thinking about people with ABPA
taking some sort of anti-fungal (like itraconazole) for
life versus taking an anti-fungal only for some period
of time during flare ups?
• Could one develop resistance to the anti-fungal over
time?

57. Q3
• anti-fungal (like itraconazole) for life in ABPA
– Not always necessary
– May be necessary in frequent relapses.
• anti-fungal only for some period of time during flare
ups?
– Not advisable,
– resistance,
– infective and of no use

58. Q4
• In addition to being allergic to aspergillus
fumigatus, I am also allergic to other molds.
• I began allergy shots in 2009 and my doctor
did not include aspergillus fumigatus in my
shots, but he did include the other molds.
• Would it be better not to have any mold
antigen in my shots?

59. Q6: ABPA and VitD
• Is there any research showing a relationship
between ABPA and vitamin D levels in the
blood? In the past, each time I had an ABPA
flare up, my blood test showed that I was
deficient in vitamin D. I now take 5000 IU of
vitamin D3 and am now in the normal range
and have not had a flare up in almost two
years.

60. Q6: ABPA and VitD
• Strong link between Vit D deficiecy and lung
disaese
• Causal –effect relationship not well
understood.
• Studies underway at NAC.
• Paper: Chishimba L, thorax 2010. Vitamin D
and the lung.

61. Q7
• It has always been rumored not to eat fungi
related foods (i.e. mushrooms, soy sauce,
yeast based products [breads, beer, etc.]). Is
there any "science" behind this? What nutrition
counseling does the patient receive when they
receive the diagnosis of a fungal related
disorder?
• Do you recommend any vitamin and/or
supplements and is there regular testing of levels
of things like vitamin D, B-12, etc.

62. Sources of information
• National Aspergillosis Centre (
www.nationalaspergillosiscentre.org.uk)
Fungal Research Trust (www.fungalresearchtrust.org)
Aspergillus website (www.aspergillus.org.uk)
Aspergillus Blog (
http://www.aspergillusblog.blogspot.com/)
Aspergillus Trust (www.aspergillustrust.org)
Aspergillosis (www.aspergillosis.org)
Aspergilloma (www.aspergilloma.co.uk
www.aspergilloma.org
www.aspergilloma.org.uk)
SAFS (www.safs.org.uk)

64. Thanks for your attention
• Any questions?