Aspergillosis and Corticosteroids

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Aspergillus is a common mold found in soil, compost, decaying leaves, vegetation, household dust and damp environments. Its microscopic spores are present in the air, and most people breathe them in regularly without becoming ill.

Aspergillosis mainly becomes a concern in people with underlying lung disease, asthma, structural lung damage or a weakened immune system. Corticosteroids ("cortisone" or steroids), including some asthma and COPD inhalers, may also increase susceptibility because they suppress parts of the immune response.

Main forms and possible symptoms

Allergic bronchopulmonary aspergillosis (ABPA) occurs mainly in people with asthma or cystic fibrosis. Possible symptoms include wheezing, cough, shortness of breath, chest tightness, thick mucus or mucus plugs, and worsening asthma. Unlike other forms, corticosteroids may actually be used to treat ABPA because they reduce the allergic inflammation.

Aspergilloma ("fungus ball") develops when Aspergillus grows inside an existing cavity in the lung. Some people have few symptoms, but it can cause chronic cough and particularly coughing up blood.

Chronic pulmonary aspergillosis (CPA) is a longer-term disease that usually affects people whose lungs are already damaged. Possible symptoms include persistent cough, shortness of breath, fatigue, reduced exercise tolerance, loss of appetite, unexplained weight loss and coughing up blood.

Invasive pulmonary aspergillosis (IPA) is the most serious form. It mainly affects people with severely weakened immune systems, including some people receiving chemotherapy, transplantation treatment or substantial immunosuppressive therapy. Symptoms may include fever, cough, chest pain, shortness of breath, coughing up blood and rapidly worsening respiratory illness. It requires urgent medical treatment.

Corticosteroids and Aspergillosis

Corticosteroids reduce inflammation, which makes them extremely useful for conditions such as asthma and COPD. However, they can also reduce the lungs' ability to control inhaled fungal spores.

A large Danish study covering 1994–2025 found an association between corticosteroid exposure and pulmonary aspergillosis. Compared with no inhaled corticosteroid use, the adjusted rate was approximately 1.7 times higher at lower inhaled doses and 2.8 times higher at higher doses. Oral corticosteroids showed stronger associations of approximately 3 to 4 times, depending on dose.

These figures describe relative risk, not absolute risk. A 2.8-fold increase does not mean that 2.8% of inhaler users will develop aspergillosis. Pulmonary aspergillosis remains uncommon, and the study was observational, so it cannot prove that corticosteroids directly caused the infections.

People requiring high-dose steroids may also have more severe lung disease, which can itself increase the risk of aspergillosis.

For this reason, prescribed corticosteroids should not be stopped without medical advice.

How is Aspergillosis diagnosed?

There is no single test that diagnoses every type. Doctors may combine:

  • Chest CT to look for cavities, fungus balls, nodules or other lung abnormalities.
  • Aspergillus IgG, particularly when chronic pulmonary aspergillosis is suspected.
  • Aspergillus-specific IgE and total IgE, particularly for allergic aspergillosis/ABPA.
  • Sputum culture or Aspergillus PCR to look for the fungus or its DNA.
  • Galactomannan testing, especially when invasive aspergillosis is suspected.
  • Bronchoscopy with bronchoalveolar lavage (BAL) when direct sampling from the lungs is needed.

Importantly, Aspergillus IgG and IgE are not interchangeable. IgG is particularly relevant to chronic pulmonary aspergillosis, while IgE is particularly important in allergic Aspergillus disease.

Where is Aspergillus found?

Aspergillus is widespread in nature. Higher concentrations can occur around compost, soil, decaying leaves, rotting vegetation, mulch, hay, stored plant material, construction dust and damp or mold-damaged buildings.

Forests also naturally contain Aspergillus because fungi grow in soil and decomposing organic material. However, an ordinary walk through a forest is generally not considered dangerous for most people. Exposure may be greater when digging in soil or disturbing large amounts of decaying leaves, compost or rotting wood.

Exposure itself does not mean infection. Most people's immune systems clear inhaled spores without difficulty.

When symptoms should be investigated

Someone taking corticosteroids does not automatically need Aspergillus testing. However, medical assessment may be appropriate when there is persistent or worsening cough, increasing breathlessness, unexplained fatigue or weight loss, recurrent chest infections, persistent fever, unusual mucus, or coughing up blood, particularly in someone with underlying lung disease or significant immune suppression.

Significant coughing up of blood, rapidly worsening breathlessness, severe chest pain, low oxygen levels, or persistent fever with severe immune suppression requires prompt or urgent medical assessment.

The key point is that corticosteroids can increase susceptibility to certain forms of pulmonary aspergillosis, particularly at higher exposures, but the individual risk depends heavily on the dose, duration of treatment, underlying lung condition and degree of immune suppression.

References:

Inhaled and oral corticosteroid use and the risk of pulmonary aspergillosis: a Danish population-based case–control study
https://thorax.bmj.com/content/early/2026/07/30/thorax-2026-225007

Hohes Risiko für pulmonale Aspergillose nach oralen und inhalierten Kortikosteroiden
https://www.aerzteblatt.de/news/hohes-risiko-fur-pulmonale-aspergillose-nach-oralen-und-inhalierten-kortikosteroiden-74a57dd8-f2ba-4ec0-89cc-7e7f7e49b181?utm_medium=email&utm_source=CR&utm_campaign=NL-DAE_FG-Pneumologie&utm_content=Mailing_20260922

 

 

© 2025-2030 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right. Library of Congress Card Number: LCN 00-192742 ISBN: 0-9703195-0-9 

 

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