Frequency of Cystic Fibrosis
Transmembrane Conductance
Regulator Gene Mutations and 5T Allele
in Patients With Allergic
Bronchopulmonary Aspergillosis*
Eric Marchand, MD; Christine Verellen-Dumoulin, PhD; Michel Mairesse, MD;
Luc Delaunois, PhD, FCCP; Pierre Brancaleone, MD; Jean-François Rahier, BSc;
and Olivier Vandenplas, PhD
Study objective: To assess the frequency of cystic fibrosis transmembrane conductance regulator
(CFTR) gene mutations in patients with allergic bronchopulmonary aspergillosis (ABPA).
Design: Case-control study. All subjects in the study were screened for the presence of 13
mutations in the CFTR gene (R117H, 621 ⴙ 1G->T, R334 W, ⌬F508, ⌬I507, 1717–1G->A,
G542X, R553X, G551D, R1162X, 3849 ⴙ 10kbC->T, W1282X, and N1303K). Moreover, they
were also screened for the presence of the 5T variant in intron 8.
Setting: University hospital and community-based hospital.
Patients: Twenty-one white patients with ABPA participated in the study. The presence of CFTR
mutations was also investigated in 43 white subjects with allergic asthma who did not show
sensitization to Aspergillus fumigatus and in 142 subjects seeking genetic counseling for diseases
other than cystic fibrosis (CF).
Results: Six patients with ABPA were found to be heterozygous for one CFTR mutation, including
⌬F508 (n ⴝ 2), G542X (n ⴝ 1), R1162X (n ⴝ 1), 1717–1G->A (n ⴝ 1), and R117H (n ⴝ 1). The 5T
allele was not detected in ABPA patients. None of the ABPA patients showed sweat chloride
concentrations > 60 mEq/L. The frequency of CFTR mutation carriers was significantly higher in
ABPA patients (6 of 21 patients; 28.5%) than in control asthmatic subjects (2 of 43 subjects; 4.6%;
p ⴝ 0.01) and in subjects seeking genetic counseling (6 of 142 subjects; p < 0.001).
Conclusion: These findings indicate that in patients without a clinical diagnosis of CF, CFTR gene
mutations could be involved in the development of ABPA, in association with other genetic or
environmental factors.
(CHEST 2001; 119:762–767)
Key words: allergic bronchopulmonary aspergillosis; cystic fibrosis; cystic fibrosis transmembrane conductance
regulator gene.
Abbreviations: ABPA ⫽ allergic bronchopulmonary aspergillosis; CF ⫽ cystic fibrosis; CFTR ⫽ cystic fibrosis transmembrane conductance regulator; CI ⫽ confidence interval; IL ⫽ interleukin
bronchopulmonary aspergillosis (ABPA) is
A llergic
an inflammatory disorder of the airways related
to the production of specific IgE and IgG directed
against Aspergillus fumigatus.1,2 This disease is char*From the Service de Pneumologie (Drs. Marchand, Delaunois,
Brancaleone, and Vandenplas), Cliniques Universitaires de
Mont-Godinne, Université Catholique de Louvain, Yvoir; Service
de Pneumologie (Dr. Mairesse), Clinique Saint-Luc, Bouge; and
Centre de Génétique Humaine et Unité de Génétique Médicale
(Dr. Verellen-Dumoulin and Mr. Rahier), Université Catholique
de Louvain, Brussels, Belgium.
Manuscript received December 29, 1999; revision accepted
November 1, 2000.
Correspondence to: Eric Marchand, MD, Service de Pneumologie, Cliniques Universitaires de Mont-Godinne, 5530-Yvoir, Belgium; e-mail: [email protected]
acterized by recurrent episodes of eosinophilic inflammation of the airways associated with peripheral
blood eosinophilia, high levels of total IgE, asthma,
mucoid impactions of proximal bronchi, and pulmonary infiltrates. The airway inflammatory process
may have a progressive course leading to the development of chronic obstructive lung disease and
bronchiectasis of proximal distribution.
The pathophysiology of ABPA remains largely
speculative. Familial occurrence of ABPA has been
reported, suggesting a possible genetic contribution
to the disease.3,4 This possibility is further suggested
by the development of ABPA-like features in a
substantial proportion of patients with cystic fibrosis
762
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21960/ on 06/15/2017
Clinical Investigations
(CF).5–10 CF is an autosomal recessive hereditary
disorder caused by mutations of the CF transmembrane conductance regulator (CFTR) gene, which
encodes for a cyclic-adenosine monophosphate–regulated chloride channel in epithelial cells.11 CF is
characterized by chronic airway disease with proximal bronchiectasis, pancreatic exocrine insufficiency, male infertility, and elevated concentrations
of electrolytes in sweat. Clinical ABPA has been
documented in 2 to 11% of patients with CF,
although immunologic sensitization to A fumigatus
may occur with a much higher frequency.5–10 The
possibility that CFTR could play a role in the pathogenesis of ABPA is also supported by the finding12 of
a high frequency of the ⌬F508 mutation in ABPA
patients with bronchiectasis. The aim of this study was
to assess the frequency of CFTR mutations in a case
series of patients with ABPA, as compared with a
control group of subjects with allergic asthma who
did not show evidence of immunologic sensitization to
A fumigatus.
Materials and Methods
Subjects
Subjects included all patients identified as having ABPA (both
with signs of disease activity and in remission) in the diagnostic
registries of the chest medicine departments of one university
hospital (Cliniques Universitaires de Mont-Godinne) and one
community-based hospital (Cliniques St Luc, Bouge), both located in nearby Namur. The first institution cares for patients
from all Wallonia (the French-speaking part of Belgium), while
the latter mostly recruits in the Namur province. The diagnosis of
ABPA was based on the presence of at least seven of the
following eight criteria adapted from Greenberger2: (1) asthma
(documented by a 15% reversibility in FEV1 in response to
inhaled bronchodilator); (2) transient pulmonary infiltrates or
atelectasis; (3) peripheral blood eosinophilia (absolute eosinophil
count ⬎ 500/␮L); (4) immediate skin-prick test reactivity to
A fumigatus extract (wheal diameter ⬎ 3 mm as compared with
negative control); (5) specific IgE to A fumigatus ⬎ 0.35 IU/mL
by radioallergosorbent test (Phadebas Radioallergosorbent Testing or CAP; Pharmacia; Uppsala, Sweden); (6) increased total
IgE level (⬎ 450 IU/mL); (7) presence of precipitating antibodies
to A fumigatus determined using agar gel double-diffusion
technique; and (8) proximal bronchiectasis. The presence of
bronchiectasis was ascertained by high-resolution CT. Bronchiectasis was deemed to be present if the bronchial diameter was
greater than that of the accompanying artery and the bronchial
wall was thickened as compared with uninvolved areas.13,14 Atopy
was defined by the presence of a positive skin-prick test to at least
one common allergen other than molds. Patients with ABPA
were requested to perform a sweat test using the pilocarpine
iontophoresis method.15 Chloride concentrations ⬍ 40 mEq/L
were considered to be in the normal range, and values between
40 mEq/L and 60 mEq/L were in the intermediate range.16
The frequency of CFTR mutations in ABPA patients was
compared with the frequency found in 43 white individuals with
allergic asthma. These were unrelated consecutive patients with
allergic asthma seen by one of the authors (O.V.) at the Cliniques
Universitaires de Mont-Godinne. Accordingly, they were not
recruited from a registry. The absence of ABPA was based on
normal chest radiographic findings and the lack of specific IgE
and precipitins directed against A fumigatus. CFTR mutations
were also analyzed in 142 unrelated subjects seeking genetic
counseling at the Centre de Génétique Humaine (which is part of
the Cliniques Universitaires St Luc in Brussels) for reasons other
than CF in order to obtain an estimate of the frequency of CFTR
mutations in the general Belgian population (control subjects).
This center recruits in the all French-speaking Belgian population. It is located 50 kilometers from Namur.
Patients and control subjects were informed of the purpose and
procedures of the study, and each signed a statement of informed
consent. The study protocol and consent form were approved by
the Ethics Committee of the Cliniques Universitaires de MontGodinne.
Mutation Analysis
DNA was isolated from peripheral blood lymphocytes using
the NaCl extraction method and conventional techniques. Mutations and polymorphism analysis were obtained from different
polymerase chain reaction amplifications. Genomic DNA samples were screened for the following CFTR mutations: R117H/
exon 4, 621 ⫹ 1G-⬎T/intron 4, R334 W/exon 7, ⌬F508/exon 10,
⌬I507/exon 10, 1717–1G-⬎A/intron 10, G542X/exon 11, R553X/
exon 11, G551D/exon 11, R1162X/exon 19, 3849 ⫹ 10kbC-⬎T/
intron 19, W1282X/exon 20, and N1303K/exon 21. The studied
mutations accounted for approximately 85% of alleles causing CF
in the Belgian population.17,18 The ⌬I507 mutation was detected
by the formation of heteroduplex following electrophoresis on
acrylamide gel (8%). The 12 other mutations were identified
using the Elucigene CF 12 mutations kit (Astra Zeneca Diagnostics; London, UK) based on the Amplification Refractory Mutation System (Astra Zeneca Diagnostics) technology. The length of
the intron 8 polythymidine tract was investigated with the
nested-polymerase chain reaction method followed by electrophoresis. The stretch was characterized using the Gene Scan 672
software of a 373A Sequencer Perkin-Elmer/Applied Biosystem
(Perkin-Elmer; Norwalk, CT).
Statistics
Proportions were compared using two-tailed Fisher’s Exact
Test or ␹2 test. The former was calculated as the sum of the
probability of obtaining the observed contingency table plus the
probabilities of obtaining all other hypothetical tables (constructed without changing the row or column totals) that were even less
likely.19 The 95% confidence intervals (CIs) of the differences of
proportions and odds ratios were calculated using usual methods.20 A p ⬍ 0.05 was considered significant.
As others,21–23 we choose to analyze CFTR mutations and
variants of the intron 8 polythymidine tract separately. Indeed, a
linkage disequilibrium has been described between some CFTR
mutations (as ⌬F508) and the intron 8 polythymidine tract
alleles.23 Moreover, in opposition to CFTR mutations, the 5T
allele in intron 8 alone has never been shown to be associated
with various pathologic conditions, such as atypical sinopulmonary disease,22,23 or congenital bilateral absence of vas deferens.21
The presence of the 5T allele in intron 8 rather potentates the
effects of CFTR mutations in these conditions. Accordingly, we
think that CFTR mutations and intron 8 polythymidine tract
alleles deserve a separate analysis, both from a statistical and from
a physiologic point of view.
Despite a small number of patients with ABPA, the power of
the study was accurate (⬎ 80%) to detect differences between
CHEST / 119 / 3 / MARCH, 2001
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21960/ on 06/15/2017
763
the groups when hypothesizing a 30% prevalence of CFTR
mutations in ABPA patients and a normal prevalence (4%) in
allergic asthmatics. When hypothesizing (1) a fourfold increase in
the prevalence of the 5T allele in ABPA as compared to control
subjects (prevalence, 5%),21 and (2) a normal prevalence of 5T
allele in allergic asthmatics, the power of the study to detect a
difference between patients with ABPA and allergic asthmatics
was 43%. The power was 53% when comparing the frequency of
the 5T allele in ABPA patients and control subjects.
Results
Of the 28 patients with a diagnosis of ABPA and
who were alive at the time of the study, 1 patient did
not agree to participate in the study and 6 patients (2
patients from the community-based hospital) were
excluded because they did not meet the abovedetailed diagnostic criteria for ABPA. From the
remaining 21 patients, 4 patients came from the
community-based hospital (patients 5, 16, 17, 18;
Table 1). The characteristics of the 21 patients with
ABPA are presented in Table 1. Six patients (patients
1 to 6) were identified to carry one CFTR mutation,
including ⌬F508 (n ⫽ 2), G542X (n ⫽ 1), R1162X
(n ⫽ 1), 1717–1G-⬎A (n ⫽ 1), and R117H (n ⫽ 1).
The 5T intron 8 variant was not detected in ABPA
patients. One patient (patient 12) declined sweat
testing. None of the ABPA patients demonstrated a
sweat chloride level ⬎ 60 mEq/L, while two patients
(patients 5 and 13) showed a sweat chloride concentration in the intermediate range (54 mEq/L and 40
mEq/L, respectively; Table 2). There was no significant difference between ABPA patients with CFTR
mutation and those without, regarding sex, atopy,
smoking habits, age at the time of ABPA diagnosis,
and presence of A fumigatus in sputum. The frequency of documented Pseudomonas aeruginosa infection was not different in patients with a CFTR
mutation (1 of 6 patients) from that found in those
who showed no CFTR mutation (2 of 12 patients).
Among the 43 control asthmatics without sensitization to A fumigatus, 2 asthmatics (4.6%) were
identified as being heterozygous for one CFTR
mutation, including ⌬F508 and 1717–1G-⬎A. In the
group of control subjects, 6 of 142 subjects (4.2%)
were found to be heterozygous for a CFTR mutation
and 7 other subjects (4.9%) were heterozygous for
the 5T allele. The proportion of CFTR mutation
carriers in ABPA patients (6 of 21 patients; 28.5%)
was significantly higher than that found in control
asthmatics (2 of 43 asthmatics; 4.6%; p ⫽ 0.01, Fisher’s Exact Test; 95% CI for difference in proportions, 3.6 to 44.2%) and in the control subjects (6 of
142 subjects; 4.2%; p ⬍ 0.001, ␹2 test; 95% CI for
difference in proportions, 4.7 to 43.9%). This corresponds to odds ratios of 8.2 (95% CI, 1.5 to 45.2) and
Table 1—Clinical Features of Patients With ABPA*
Subject
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Age,
yr
BC
Asthma
Pulmonary
Infiltrates or
Atelectasis
30
29
64
27
63
58
55
84
59
47
60
46
79
51
48
74
30
63
67
58
74
⫹
⫹
⫹
⫹
⫹
⫺
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫺
⫺
⫺
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫺
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫺
⫺
⫹
⫹
⫹
⫹
Blood
Eosinophils,†
cells/␮L
2,020
1,450
1,830
680
640
400
1,340
2,440
4,260
1,960
730
900
1,110
1,320
660
1,600
650
640
860
580
1,100
Total IgE,†
IU/mL
Specific IgE
to A
fumigatus,†
IU/mL
Precipitin to A
fumigatus,†
(No. of Lines)
A fumigatus
in Sputum
1,947
1,463
2,277
4,642
888
953
3,652
1,762
3,210
2,294
1,188
709
487
645
2,549
3,101
2,574
1,123
2,287
1,374
1,853
30.6
35.8
72.1
88.6
14.6
6.8
12.2
24.1
80.1
32.6
31.3
15.3
32.6
1.5
58.7
55.9
53.6
27.6
52.8
78.9
3.0
⫹ (6)
⫹ (2)
⫹ (1)
⫹ (2)
⫹ (3)
⫹ (2)
⫹ (4)
⫹ (1)
⫹ (1)
⫹ (3)
⫹ (1)
⫹ (2)
⫹ (1)
⫹ (1)
⫹ (2)
⫹ (5)
⫹ (2)
⫹ (2)
⫹ (2)
⫹ (3)
⫹ (2)
⫹
⫹
⫹
⫺
⫺
⫺
⫹
⫹
⫹
⫺
⫹
⫹
⫹
⫺
NA
NA
NA
⫹
⫹
⫺
⫹
*BC ⫽ bronchiectasis; NA ⫽ not available; ⫹ ⫽ yes; ⫺ ⫽ no.
†Highest recorded value.
764
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21960/ on 06/15/2017
Clinical Investigations
Table 2—CF-Related Features of Patients With ABPA*
Subject Sweat Chloride,†
Intron 8 Polythymidine
No.
mEq/L
CFTR Mutation
Tract Alleles
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
17
33
6
38
54
8
36
23
14
19
37
NA
40
38
14
19
32
15
34
13
34
⌬F508
⌬F508
G542X
R1162X
1717-1G3A
R117H
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
7T/9T
7T/9T
7T/9T
7T/7T
7T/7T
7T/9T
7T/7T
7T/7T
7T/7T
7T/7T
7T/7T
7T/7T
7T/7T
7T/7T
7T/7T
7T/7T
7T/7T
7T/7T
7T/9T
7T/7T
7T/7T
*See Table 1 for expansion of abbreviation.
†Highest recorded value.
9.1 (95% CI, 2.6 to 31.7) when comparing patients
with ABPA with allergic asthmatics and control
subjects, respectively.
Two allergic asthmatics (4.6%) and seven control
subjects (4.9%) were found to be heterozygous for
the 5T variant in intron 8. None of the 5T carriers
were heterozygous for CFTR mutations. The differences in proportions of 5T carriers were not statistically significant between the three groups (Fisher’s
Exact Test).
Discussion
In this study, we found the frequency of the
studied CFTR mutations to be significantly higher in
ABPA patients than it was in either allergic asthmatics without sensitization to A fumigatus or in subjects
seeking genetic counseling for reasons other than
CF. These findings are consistent with those reported in a study by Miller et al,12 although we
identified a wider spectrum of CFTR mutations in
ABPA patients. These investigators12 analyzed the
coding region of the CFTR gene in 11 white patients
from four university centers who were identified as
having ABPA, central bronchiectasis, and normal
sweat chloride levels. One of these patients was
identified as a compound heterozygote (⌬F5085/
R347H), and she was reclassified as having atypical
CF. Five patients were found to carry one CFTR
mutation, including ⌬F508 in four patients and
R117H in one patient. The proportion of patients
who were excluded because they did not fulfill the
proposed diagnostic criteria for ABPA was higher in
our population (21%) than in the study by Miller et
al12 (4%). However, participation in genetic testing
was higher in our group of ABPA patients (95% vs
24%). As our sample of patients with ABPA came
from both community-based and university hospitals,
we think that it was representative for the cases of
ABPA that come to the attention of lung specialists.
The higher-than-expected frequency of CFTR
mutations among ABPA patients raises two hypotheses. First, the patients found to be heterozygous for
the studied mutations could actually present an
atypical form of CF, as they could carry another rare
CFTR mutation on the second chromosome. Because we did not analyze the complete coding sequence of the CFTR gene, we cannot formally
exclude that our ABPA patients were compound
heterozygotes for unidentified CFTR mutations.
This possibility, however, would imply that a substantial proportion of patients with ABPA have unrecognized CF. None of our patients with ABPA
showed elevated sweat chloride concentrations. Accordingly, they did not meet the usual diagnostic
criteria for CF.11 One patient with a CFTR mutation
was found to have a sweat chloride level in the
intermediate range. This patient did not show other
evidence of CF, such as P aeruginosa infection or
pancreatic insufficiency. However, previous genetic
studies24 –29 have provided accumulating evidence
that some CFTR mutations are associated with
milder CF phenotypes and normal sweat electrolytes. In the study by Miller et al,12 only one ABPA
patient was identified as carrying two CFTR mutations (⌬F508/R347H). This patient presented with
recurrent P aeruginosa pneumonia, normal sweat
electrolytes, and abnormal values of nasal transepithelial voltage measurements. The presence of
P aeruginosa in sputum was not more frequent in our
ABPA patients with a CFTR mutation than in those
without mutation. Nasal potential differences were
not measured in our patients. This test deserves
further investigation in patients with ABPA, as it
could represent a more reliable indicator of CFTR
function than the sweat test.
Besides mutations of the CFTR gene, genetic
polymorphism of noncoding regions may have an
impact on the level of functional CFTR and CF
phenotype.30 In addition, mutations of the noncoding regions of CFTR have been associated with
atypical CF phenotypes. For instance, the 5T allele
sequence in intron 8 results in the deletion of exon 9
in CFTR messenger RNA, leading to reduced levels
of the normal CFTR protein. The combination of
CHEST / 119 / 3 / MARCH, 2001
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21960/ on 06/15/2017
765
one CFTR mutation with the 5T allele has been
involved in the pathogenesis of congenital bilateral
absence of vas deferens21 and atypical sinopulmonary disease.22,23 Among the ABPA patients studied
by Miller et al,12 the 5T intron 8 variant was
identified in two patients without other mutations in
the CFTR gene.12 By contrast, we did not detect the
5T allele in our ABPA patients. This is probably
explained by the small number of ABPA patients that
is inherent to the rarity of the disorder and which
precludes to draw definitive conclusions on the role
of this variant in ABPA.
Alternatively, our findings, together with those of
Miller et al,12 could indicate that heterozygosity for
CFTR mutations has a specific effect on the development of ABPA, at least in a subset of patients.
Heterozygosity for CFTR mutations could either
predispose to the development of bronchiectasis
with secondary sensitization to A fumigatus or promote immune response to A fumigatus, leading to
airway inflammation and bronchiectasis. Whether
CF carrier status is associated with an increased risk
of pulmonary disease remains a matter of debate. A
higher prevalence of bronchial hyperresponsiveness
to methacholine, wheezing, and lung disease during
childhood, as well as a decrease in expiratory volumes and flows have been found in obligate heterozygotes for CF.31,32 An increased prevalence of
reported asthma in adult heterozygotes for the
⌬F508 mutation has been reported in some33 but not
all studies.34,35 Previous studies36,37 have convincingly documented a high prevalence of CFTR mutations in adult patients with disseminated bronchiectasis of unknown etiology. By altering the
mucociliary clearance process, bronchiectasis could
lead to chronic airway colonization with A fumigatus
hyphae, which is thought to be a prerequisite to the
development of immunologic sensitization to A fumigatus.1,2 In the study by Gervais et al,36 the
presence of ABPA was not mentioned, while 2 of the
16 patients studied by Pignatti et al37 had ABPA, and
1 of these 2 patients was heterozygous for a rare
mutation (3667 ins 4). Another possibility is that
CFTR mutations contribute to enhanced immunologic and inflammatory responses to A fumigatus. An
epidemiologic survey35 found a higher prevalence of
positive skin-prick tests to A fumigatus in ⌬F508
carriers than in noncarriers, although there was no
difference in the prevalence of asthma. In addition,
there is emerging evidence that CF is associated with
altered production of cytokines in the airways, including interferon-␥, interleukin (IL)-8, and IL-10,
which could result in inappropriately regulated inflammatory and immunologic processes.38,39 Peripheral CD4⫹ T cells derived from CF patients have
been found to produce reduced levels of IL-10 after
polyclonal activation.40 IL-10 has potent anti-inflammatory effects by reducing the release of various
proinflammatory cytokines. Assessing the prevalence
of CF carriers in ABPA patients who lack demonstrable bronchiectasis41 would help to elucidate the
role of CFTR mutations in the development of
ABPA. None of the three ABPA patients without
bronchiectasis included in our study was found to
carry CFTR mutations, although their number was
too low to draw any reliable conclusions.
A limitation of this study is the small number of
subjects included, particularly in the group of patients with ABPA. This is inherent to the rarity of the
disorder. However, the power of the study was
accurate (see “Materials and Methods”) to detect
differences in CFTR-mutations frequency. In ABPA
as in other conditions associated with CFTR mutations,21–23 the difference in prevalence of the 5T
allele with a control population seems to be less
dramatic. Regarding the 5T allele frequency, the
power of our study was relatively weak. Still, we
choose to analyze the 5T allele in the present study
because of its potential role when associated with a
CFTR mutation. Larger multicentric studies including a greater number of patients are needed to
resolve the issue of the association of the 5T allele
and ABPA as well as the prevalence of CFTR gene
mutations in patients suffering from ABPA without
bronchiectasis. The present study as well as that by
Miller et al12 demonstrate a high odds ratio for
carrying a CFTR mutation in patients with ABPA.
However, the CIs for odds ratios were wide. Larger
studies would also allow to confirm these impressive
odds ratios.
In conclusion, this study indicates that CFTR gene
mutations, in combination with environmental or
other genetic factors, could be involved in the pathogenesis of ABPA in patients who do not meet the
clinical criteria for CF. Further investigation is warranted to assess the impact of CFTR dysfunction on
airway response to A fumigatus. The high frequency
of heterozygotes for a CFTR mutation among ABPA
patients suggests that CFTR genotyping should be
proposed to patients with this disease in order to
provide appropriate genetic counseling.
ACKNOWLEDGMENT: The authors thank Mss. N. Lanoy and
C. Walon for their assistance in performing genetic studies, Dr.
J. Jamart for performing statistical analysis, and Mrs. L. Schubert
for reviewing the article.
References
1 Kauffman HF, Tomee JF, van der Werf TS, et al. Review of
fungus-induced asthmatic reactions. Am J Respir Crit Care
Med 1995; 151:2109 –2115
2 Greenberger PA. Immunologic aspects of lung diseases and
cystic fibrosis. JAMA 1997; 278:1924 –1930
766
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21960/ on 06/15/2017
Clinical Investigations
3 Starke ID. Asthma and allergic aspergillosis in monozygotic
twins. Br J Dis Chest 1985; 79:295–300
4 Shah A, Khan ZU, Chaturvedi S, et al. Concomitant allergic
Aspergillus sinusitis and allergic bronchopulmonary aspergillosis associated with familial occurrence of allergic bronchopulmonary aspergillosis. Ann Allergy 1990; 64:507–512
5 Laufer P, Fink JN, Bruns WT, et al. Allergic bronchopulmonary aspergillosis in cystic fibrosis. J Allergy Clin Immunol
1984; 73:44 – 48
6 Zeaske R, Bruns WT, Fink JN, et al. Immune responses to
Aspergillus in cystic fibrosis. J Allergy Clin Immunol 1988;
82:73–77
7 Simmonds EJ, Littlewood JM, Evans EG. Cystic fibrosis and
allergic bronchopulmonary aspergillosis. Arch Dis Child
1990; 65:507–511
8 el Dahr JM, Fink R, Selden R, et al. Development of immune
responses to Aspergillus at an early age in children with cystic
fibrosis. Am J Respir Crit Care Med 1994; 150:1513–1518
9 Becker JW, Burke W, McDonald G, et al. Prevalence of
allergic bronchopulmonary aspergillosis and atopy in adult
patients with cystic fibrosis. Chest 1996; 109:1536 –1540
10 Wojnarowski C, Eichler I, Gartner C, et al. Sensitization to
Aspergillus fumigatus and lung function in children with
cystic fibrosis. Am J Respir Crit Care Med 1997; 155:1902–
1907
11 Davis PB, Drumm M, Konstan MW. Cystic fibrosis. Am J
Respir Crit Care Med 1996; 154:1229 –1256
12 Miller PW, Hamosh A, Macek M Jr, et al. Cystic fibrosis
transmembrane conductance regulator (CFTR) gene mutations in allergic bronchopulmonary aspergillosis. Am J Hum
Genet 1996; 59:45–51
13 Neeld DA, Goodman LR, Gurney JW, et al. Computerized
tomography in the evaluation of allergic bronchopulmonary
aspergillosis. Am Rev Respir Dis 1990; 142:1200 –1205
14 Angus RM, Davies ML, Cowan MD, et al. CT scanning of the
lung in patients with allergic bronchopulmonary aspergillosis
and in asthmatic patients with a positive skin test to Aspergillus fumigatus. Thorax 1994; 49:586 –589
15 Gibson LF, Cooke RE. A test for concentration of electrolytes
in sweat in cystic fibrosis of the pancreas utilizing pilocarpine
iontophoresis. Pediatrics 1959; 23:545–549
16 Davis PB, Del Rio S, Muntz JA, et al. Sweat chloride
concentration in adults with pulmonary diseases. Am Rev
Respir Dis 1983; 128:34 –37
17 Cuppens H, Marynen P, De Boeck C, et al. Detection of
98.5% of the mutations in 200 Belgian cystic fibrosis alleles by
reverse dot-blot and sequencing of the complete coding
region and exon/intron junctions of the CFTR gene. Genomics 1993; 18:693– 697
18 Population variation of common cystic fibrosis mutations: the
Cystic Fibrosis Genetic Analysis Consortium. Hum Mutat
1994; 4:167–177
19 Motulsky H. Comparing observed and expected counts. In:
Motulsky H, ed. Intuitive biostatistics. New York, NY: Oxford
University Press, 1995; 233–242
20 Motulsky H. Confidence interval of the difference or ratio of
two proportions: prospective studies. In: Motulsky H, ed.
Intuitive biostatistics. New York, NY: Oxford University
Press, 1995; 70 – 89
21 Chillon M, Casals T, Mercier B, et al. Mutations in the cystic
fibrosis gene in patients with congenital absence of the vas
deferens. N Engl J Med 1995; 332:1475–1480
22 Kerem E, Rave-Harel N, Augarten A, et al. A cystic fibrosis
transmembrane conductance regulator splice variant with
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
partial penetrance associated with variable cystic fibrosis
presentations. Am J Respir Crit Care Med 1997; 155:1914 –
1920
Friedman KJ, Heim RA, Knowles MR, et al. Rapid characterization of the variable length polythymidine tract in the
cystic fibrosis (CFTR) gene: association of the 5T allele with
selected CFTR mutations and its incidence in atypical sinopulmonary disease. Hum Mutat 1997; 10:108 –115
Strong TV, Smit LS, Turpin SV, et al. Cystic fibrosis gene
mutation in two sisters with mild disease and normal sweat
electrolyte levels. N Engl J Med 1991; 325:1630 –1634
Gasparini P, Borgo G, Mastella G, et al. Nine cystic fibrosis
patients homozygous for the CFTR nonsense mutation
R1162X have mild or moderate lung disease. J Med Genet
1992; 29:558 –562
Augarten A, Kerem BS, Yahav Y, et al. Mild cystic fibrosis and
normal or borderline sweat test in patients with the 3849 ⫹
10 kb C–⬎T mutation. Lancet 1993; 342:25–26
Stewart B, Zabner J, Shuber AP, et al. Normal sweat chloride
values do not exclude the diagnosis of cystic fibrosis. Am J
Respir Crit Care Med 1995; 151:899 –903
Highsmith WE, Burch LH, Zhou Z, et al. A novel mutation in
the cystic fibrosis gene in patients with pulmonary disease but
normal sweat chloride concentrations. N Engl J Med 1994;
331:974 –980
Gan KH, Veeze HJ, van den Ouweland AM, et al. A cystic
fibrosis mutation associated with mild lung disease. N Engl
J Med 1995; 333:95–99
Kiesewetter S, Macek M Jr, Davis C, et al. A mutation in
CFTR produces different phenotypes depending on chromosomal background. Nat Genet 1993; 5:274 –278
Davis PB. Autonomic and airway reactivity in obligate heterozygotes for cystic fibrosis. Am Rev Respir Dis 1984;
129:911–914
Davis PB, Vargo K. Pulmonary abnormalities in obligate
heterozygotes for cystic fibrosis. Thorax 1987; 42:120 –125
Dahl M, Tybjaerg-Hansen A, Lange P, et al. ⌬F508 heterozygosity in cystic fibrosis and susceptibility to asthma. Lancet
1998; 351:1911–1913
Schroeder SA, Gaughan DM, Swift M. Protection against
bronchial asthma by CFTR ⌬F508 mutation: a heterozygote
advantage in cystic fibrosis. Nat Med 1995; 1:703–705
Kauffmann F, Chomel JC, Kitzis A, et al. ⌬F508 heterozygosity and asthma: EGEA-operative Group. Lancet 1998;
352:985–986
Gervais R, Lafitte JJ, Dumur V, et al. Sweat chloride and
⌬F508 mutation in chronic bronchitis or bronchiectasis [letter]. Lancet 1993; 342:997
Pignatti PF, Bombieri C, Marigo C, et al. Increased incidence
of cystic fibrosis gene mutations in adults with disseminated
bronchiectasis. Hum Mol Genet 1995; 4:635– 639
Bonfield TL, Panuska JR, Konstan MW, et al. Inflammatory
cytokines in cystic fibrosis lungs. Am J Respir Crit Care Med
1995; 152:2111–2118
Warner JO, Kilburn SA. Cystic fibrosis and allergy. Pediatr
Allergy Immunol 1996; 7:67– 69
Moss RB, Bocian RC, Hsu YP, et al. Reduced IL-10 secretion
by CD4⫹ T lymphocytes expressing mutant cystic fibrosis
transmembrane conductance regulator (CFTR). Clin Exp
Immunol 1996; 106:374 –388
Greenberger PA, Miller TP, Roberts M, et al. Allergic
bronchopulmonary aspergillosis in patients with and without
evidence of bronchiectasis. Ann Allergy 1993; 70:333–338
CHEST / 119 / 3 / MARCH, 2001
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21960/ on 06/15/2017
767