The problems of treatment in bronchopulmonary aspergillosis are discussed and illustrated by 11 case reports—four with aspergilloma, six with allergic aspergillosis, and two with probable allergic aspergillosis. A simple and effective treatment of aspergilloma, by local surgical evacuation of the cavity followed by irrigation with natamycin (Pimaricin), is described in three cases. Prior treatment of these cases with inhalations or intrabronchial instillations of natamycin was of doubtful benefit. The therapy of allergic aspergillosis is reviewed and an active approach is urged, based on the probable pathogenesis of the disease. This includes consideration of physical methods of removing bronchial plugs, mucolytic agents, steroids, and antifungal drugs given by aerosol in the absence of any that are suitable for systemic use. Steroids improved ventilatory function and were effective in resolving and preventing further episodes of pulmonary eosinophilia, but not usually in clearing the fungus from the bronchial tree, probably because permanent damage had already been sustained; they also carry the theoretical risk of allowing fungal invasion. Natamycin inhalations alone are considered of little value in the active disease, although their place in prophylaxis and when used with steroids remains to be evaluated. Mucolytic agents may help to clear the bronchial secretions, especially when these have become chronically impacted.
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