Pulmonology

Building Your Understanding of ABPA

At a Glance

Allergic bronchopulmonary aspergillosis (ABPA) is an immune overreaction to Aspergillus mold in the airways, not usually an invasive infection. It can cause poorly controlled asthma, high IgE, thick mucus plugs, breathing problems, and lasting airway damage called bronchiectasis.

If you have lived for years with asthma or cystic fibrosis that never quite seems under control, receiving a diagnosis of Allergic Bronchopulmonary Aspergillosis (ABPA) can feel like finally finding the missing piece of a puzzle. Many patients describe a cycle of frustration—repeatedly being told their asthma is “severe” or “difficult” while treatments that work for others fail to provide relief ^[1]^[2].

ABPA is not a typical infection. While most fungal lung diseases involve the mold attacking your tissues, ABPA is an exaggerated immune response ^[3]. Your body is overreacting to a common mold called Aspergillus fumigatus, which lives in the air around us every day ^[4].

An Overreaction, Not an Invasion

In most people, breathing in Aspergillus spores is harmless because the immune system quietly clears them away. However, in people with ABPA, the mold begins to live (or colonize) in the mucus of the airways ^[4].

Critically, the mold does not usually invade the lung tissue itself—a life-threatening condition called invasive aspergillosis that typically only affects people with severely weakened immune systems ^[3]^[5]. Instead, in ABPA, your immune system sees the mold as a major threat and launches a misplaced inflammatory counterattack ^[6]. This is a hypersensitivity response, meaning your body’s defense system is doing more damage than the mold itself ^[7].

The Biological Response in Your Lungs

When your immune system detects the mold, it triggers a specific type of inflammation called Type 2 inflammation ^[6]. This process involves several key players:

IgE (Immunoglobulin E): These are allergy-related antibodies. In ABPA, your Total IgE levels often rise significantly—frequently rising above 500 or even 1,000 IU/mL—as your body tries to “fight” the mold ^[8].
Eosinophils: These are a type of white blood cell. While they are meant to protect you, in ABPA, they swarm the airways in high numbers (a state called eosinophilia) ^[9].
Cytokines: These are chemical messengers (like IL-4, IL-5, and IL-13) that tell your body to keep producing more IgE and more eosinophils, creating a self-sustaining loop of inflammation ^[6]^[7].

How Inflammation Changes Your Airway

This constant immune battle causes physical changes that explain your symptoms:

Thick Mucus: The inflammation makes your mucus incredibly thick and “rubbery.” These mucus plugs can block your small airways, making it hard to breathe and often appearing as “shadows” on imaging ^[10]^[11].
Brownish Phlegm: Patients often report coughing up distinctive, brownish or tea-colored plugs of mucus ^[12].
Airway Damage: Over time, the aggressive immune response can weaken the walls of your airways, leading to bronchiectasis—a condition where the airways become permanently scarred and widened ^[11]^[13].

Who is Most at Risk?

ABPA is usually associated with people who already have a “predisposing” lung condition. It acts as a complication that makes the original disease much harder to manage ^[8]. The estimates below vary widely depending on the geography, the population studied, and the strictness of the diagnostic criteria used.

Underlying Condition	Estimated Prevalence of ABPA
Asthma	Between 1% and 13% of patients, especially those with severe or “steroid-dependent” asthma ^[14]^[15].
Cystic Fibrosis (CF)	Approximately 9% of patients, though some clinics report up to 15% ^[16].
Bronchiectasis	About 4% of people with non-CF bronchiectasis ^[13].

Recent medical guidelines have also recognized that people with COPD (Chronic Obstructive Pulmonary Disease) may occasionally develop ABPA-like responses ^[8]^[17].

Understanding that your symptoms come from an allergy to a fungus—rather than just “worsening asthma”—is the first step toward a treatment plan that addresses the root cause: calming your immune system’s overreaction. It is crucial to remember that treating ABPA does not replace your standard care; you must continue managing your underlying asthma, CF, or COPD with your prescribed therapies.

Common questions in this guide

Is ABPA an infection or an allergic reaction?

ABPA is mainly an exaggerated allergic immune response to Aspergillus fumigatus in airway mucus, not usually a mold infection that invades lung tissue. Invasive aspergillosis is a different, more serious infection that typically affects people with severely weakened immune systems.

Who is most likely to develop ABPA?

ABPA most often affects people with asthma, particularly severe or steroid-dependent asthma, and people with cystic fibrosis. It can also occur in people with non-CF bronchiectasis and, less often, COPD.

What symptoms can ABPA cause?

ABPA can make asthma or other breathing symptoms hard to control and may cause difficulty breathing. People may cough up thick, brownish, or tea-colored mucus plugs, and blood-streaked phlegm can also occur.

What do IgE and eosinophils mean in ABPA?

Total IgE is an allergy-related antibody that often becomes very high in ABPA, while eosinophils are white blood cells that may increase during the immune response. Clinicians may consider these results along with Aspergillus-specific IgE or IgG tests, imaging, and sputum findings.

Can ABPA cause permanent lung damage?

Repeated inflammation can make mucus thick and weaken airway walls. Over time, this can lead to bronchiectasis, in which the airways become permanently widened and scarred.

How do doctors check or monitor ABPA over time?

Monitoring may include changes in symptoms, total IgE, eosinophils, and imaging or sputum findings. Your clinician uses the pattern over time to judge whether the immune reaction is improving.

Should I continue my usual treatment for asthma or another lung condition?

Yes—treatment for ABPA does not replace prescribed care for the underlying asthma, cystic fibrosis, or COPD. Your healthcare team can decide whether you need additional treatment aimed at the allergic response.

Answer a question to get research tailored to you. Your answers are private.

Get notified when new evidence is published on Allergic bronchopulmonary aspergillosis.

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Curated prompts to bring to your next appointment.

1.What was my total IgE level, and how does it compare to the threshold for an ABPA diagnosis?
2.Do I have 'sensitization' to Aspergillus, and what specific tests (like IgE or IgG) confirmed this?
3.Based on my imaging or sputum, do I have signs of bronchiectasis or mucus plugging?
4.Are my current asthma or cystic fibrosis medications sufficient, or do we need to add treatments specifically for this allergic response?
5.How will we monitor whether my immune system's reaction to the mold is improving over time?

References (17)

1
[Clinical features and reasons for missed diagnosis of allergic bronchopulmonary aspergillosis].
Zou MF, Li S, Yang Y, et al.
Zhonghua yi xue za zhi 2019; (99(16)):1221-1225 doi:10.3760/cma.j.issn.0376-2491.2019.16.006.
PMID: 31060160
2
Clinical Characteristics and Prognosis of Allergic Bronchopulmonary Aspergillosis: A Retrospective Cohort Study.
Zeng Y, Xue X, Cai H, et al.
Journal of asthma and allergy 2022; (15()):53-62 doi:10.2147/JAA.S345427.
PMID: 35046669
3
[Allergic bronchopulmonary aspergillosis in internal medicine].
Chedal-Anglay C, Martin de Frémont G, Dupin C
La Revue de medecine interne 2026; (47(4)):184-193 doi:10.1016/j.revmed.2026.01.008.
PMID: 41856838
4
The Triad of Pathogenesis in Allergic Bronchopulmonary Aspergillosis: Interactions among <italic>Aspergillus fumigatus</italic>, Epithelium, and Immunity.
Wang Y, Zhang L, Sun Y, Zhang Y
International archives of allergy and immunology 2025; 1-14 doi:10.1159/000547550.
PMID: 40738023
5
Manifestations of pulmonary aspergillosis in pediatrics.
Chacko A, Moss RB
Current opinion in pediatrics 2020; (32(3)):389-394 doi:10.1097/MOP.0000000000000898.
PMID: 32371841
6
Interplay of Cytokines and Chemokines in Aspergillosis.
Shankar J, Thakur R, Clemons KV, Stevens DA
Journal of fungi (Basel, Switzerland) 2024; (10(4)) doi:10.3390/jof10040251.
PMID: 38667922
7
T helper 2 response in allergic bronchopulmonary aspergillosis is not driven by specific Aspergillus antigens.
Jolink H, de Boer R, Willems LN, et al.
Allergy 2015; (70(10)):1336-9 doi:10.1111/all.12688.
PMID: 26179335
8
Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses.
Agarwal R, Sehgal IS, Muthu V, et al.
The European respiratory journal 2024; (63(4)) doi:10.1183/13993003.00061-2024.
PMID: 38423624
9
Mepolizumab as Possible Treatment for Allergic Bronchopulmonary Aspergillosis: A Review of Eight Cases.
Tolebeyan A, Mohammadi O, Vaezi Z, Amini A
Cureus 2020; (12(8)):e9684 doi:10.7759/cureus.9684.
PMID: 32923277
10
Allergic Bronchopulmonary Aspergillosis-A Luminal Hypereosinophilic Disease With Extracellular Trap Cell Death.
Ueki S, Hebisawa A, Kitani M, et al.
Frontiers in immunology 2018; (9()):2346 doi:10.3389/fimmu.2018.02346.
PMID: 30364279
11
Does ABPA Contribute to Bronchiectasis? A Structured Evaluation of Competing Hypotheses.
Agarwal R, Sehgal IS, Muthu V, Bardin P
Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology 2026; (56(5)):498-505 doi:10.1111/cea.70299.
PMID: 41943086
12
Prevalence and Risk Factors of Allergic Bronchopulmonary Aspergillosis and Aspergillus Sensitization in Children with Poorly Controlled Asthma.
Kumari J, Jat KR, Lodha R, et al.
Journal of tropical pediatrics 2020; (66(3)):275-283 doi:10.1093/tropej/fmz066.
PMID: 31580457
13
Allergic bronchopulmonary aspergillosis and Aspergillus-related airway diseases in bronchiectasis: a narrative review.
Agarwal R, Chotirmall SH, Chalmers JD
Journal of thoracic disease 2025; (17(12)):11501-11519 doi:10.21037/jtd-2025-1548.
PMID: 41522133
14
Prevalence of allergic bronchopulmonary aspergillosis in asthmatic patients: A prospective institutional study.
Kalaiyarasan , Jain AK, Puri M, et al.
The Indian journal of tuberculosis 2018; (65(4)):285-289 doi:10.1016/j.ijtb.2018.04.007.
PMID: 30522614
15
Allergic bronchopulmonary aspergillosis.
Agarwal R, Sehgal IS, Dhooria S, et al.
The Indian journal of medical research 2020; (151(6)):529-549 doi:10.4103/ijmr.IJMR_1187_19.
PMID: 32719226
16
Prevalence of Aspergillus sensitization and allergic bronchopulmonary aspergillosis in cystic fibrosis: systematic review and meta-analysis.
Maturu VN, Agarwal R
Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology 2015; (45(12)):1765-78 doi:10.1111/cea.12595.
PMID: 26177981
17
Prevalence of allergic bronchopulmonary aspergillosis/Aspergillus sensitization in chronic obstructive pulmonary disease: A systematic review and meta-analysis.
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PMID: 42361722

This page explains the immune response and airway changes in ABPA for informational purposes only and is not medical advice. Ask your healthcare professional to interpret your IgE, imaging, sputum, and treatment results for your situation.

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