Chronic pulmonary aspergillosis (CPA) is a common sequela of pulmonary tuberculosis (TB). The diagnosis of CPA is difficult and often misdiagnosed as smear-negative TB in endemic settings. Aspergillus IgG detection is the cornerstone of CPA diagnosis. There are a lack of studies on the prevalence of CPA in GeneXpert/smear-negative TB patients in Indonesia, despite a high number of TB cases. This study aims to determine the CPA rate in HIV-negative, GeneXpert-negative patients presenting with symptoms following completion of TB therapy and to evaluate the performance of LDBio Aspergillus immunochromatographic technology (ICT) lateral flow assay in the diagnosis of CPA. CPA was diagnosed on the basis of symptoms for ≥3 months, characteristic chest imaging and positive Aspergillus culture. Twenty (22%) out of 90 patients met the criteria for CPA. The LDBio test was positive in 16 (80%) CPA patients and in 21 (30%) non-CPA patients (p < 0.001) with 80% sensitivity and 70% specificity. Logistic regression revealed a positive LDBio Aspergillus ICT result, smoking history and diabetes to be important predictors of CPA diagnosis. Although CPA is an unrecognised disease in Indonesia, this study suggests that more than one in five GeneXpert negative patients with persistent symptoms following completion of TB therapy may have CPA.

The detection of Aspergillus antibody has a key role in the diagnosis of chronic pulmonary aspergillosis. Western blot (WB) and immunochromatography (ICT) lateral flow detection of Aspergillus antibody can be used as confirmatory and screening assays but their comparative performance in TB patients is not known. This study investigated the performance of these assays among 88 post-tuberculosis patients with suspected CPA. Sensitivity, specificity, receiver operating curve (ROC), area under-curve (AUC) and the agreement between two assays were evaluated. Both WB and ICT showed good sensitivity (80% and 85%, respectively) for detection of Aspergillus antibodies. Substantial agreement (0.716) between these assays was also obtained. The highest AUC result (0.804) was achieved with the combination of WB and ICT. The global intensity of WB correlated with the severity of symptoms in CPA group (p = 0.001). The combination of WB and ICT may increase specificity in CPA diagnosis.

Cryptic species of Aspergillus have rapidly increased in the last few decades. Chronic pulmonary aspergillosis (CPA) is a debilitating fungal infection frequently affecting patients with previous TB. The identification and antifungal susceptibility profiles of different species of Aspergillus are important to support the management of CPA. The aim of this study was to describe the molecular and susceptibility profiles of Aspergillus isolated from CPA patients. The species identity of isolates was determined by combined DNA analyses of internal transcribed space (ITS), partial β-tubulin genes, and part of the calmodulin gene. We revealed a high (27%) prevalence of cryptic species among previous tuberculosis patients with persistent symptoms. Twenty-nine (49%) patients met the criteria for diagnosis of CPA with 24% containing Aspergillus cryptic species. This is the first report of five cryptic Aspergillus species from clinical isolates in Indonesia: A. aculea tus, A. neoniger, A. brunneoviolacues, A. welwitschiae, and A. tubingensis. Significantly, there was decreased sensitivity against itraconazole in the CPA group (66% susceptible to itraconazole) compared to the non-CPA group (90% susceptible to itraconazole) (p = 0.003). The species-level characterisation of Aspergillus and its antifungal susceptibility tests demands greater attention to better the management of CPA patients.

Histoplasmosis is a common disease among immunocompromised patients and a notable endemic disease among immunocompetent patients. Disseminated histoplasmosis in acquired immunodeficiency syndrome (AIDS) patients is mostly lethal. We conducted a literature review of histoplasmosis and histoplasmin skin test in Asia. There were around 1692 cases of histoplasmosis reported from Asian countries. India (623 cases), China (611 cases) and Thailand (234 cases) are detected as endemic areas of histoplasmosis although the complete mapping of this disease is still missing in some Asian countries. However, definite diagnosis is difficult since the symptoms frequently mimicking tuberculosis (TB), tissue samples are rarely obtained, and lacked of serology tests in Asian countries.

Tuberculosis (TB) is the main risk factor for chronic pulmonary aspergillosis, especially in patients with residual cavitary lesions after completion of TB therapy. The body mass index (BMI) is one of the established markers in predicting the mortality of CPA. However, the data regarding BMI profiles of CPA patients in Indonesia is still limited. We evaluated the BMI profiles of CPA patients among post-TB patients. Patients diagnosed as CPA based on clinical, radiology and the Aspergillus IgG test. 50 patients were included with a mean age of 35 years; 13 patients met the criteria of CPA. The overall median of BMI in these patients was 21. The median BMI in the CPA group was 19,3. The lowest (19,8) median BMI value was observed in the positive Aspergillus IgG group (11,5 – 30 mg/L) with a minimum BMI of 14,7 and a maximum BMI of 29,2. The differences in median BMI across CPA and non CPA groups and Aspergillus IgG level were not statistically significant. However, there is a trend that lower BMI were distributed among patients with positive Aspergillus IgG. More than one third of CPA patients in this study were classified as underweight. Future study is necessary to better depict the BMI profiles in larger scale of populations of CPA in Indonesia in order to achieve better diagnosis and management of CPA.