Prevalence of Chronic Pulmonary Aspergillosis in Patients With Mycobacterial and Non-Mycobacterial Tuberculosis Infection of the Lung: A Systematic Review and Meta-Analysis

Background Post-mycobacterial residual lung abnormality (PMLA) from prior tuberculous (PTLA) or non-tuberculous mycobacterial (PNTLA) lung infections predisposes to chronic pulmonary aspergillosis (CPA). However, the prevalence of CPA in patients with PMLA remains uncertain. We aimed to determine the prevalence of CPA in patients with PMLA. Methods We performed a systematic search of PubMed and Embase databases up to January 31, 2025, to identify studies reporting CPA prevalence in patients with PTLA or PNTLA (excluding those with active tuberculosis). The pooled prevalence was calculated using frequentist meta-analysis (primary outcome), with Bayesian and trim-and-fill methods as sensitivity analyses. Study heterogeneity (I 2 ) and publication bias were assessed. We performed multivariable meta-regression to evaluate factors affecting heterogeneity. Results Thirty-one studies (4172 PTLA and 13,905 PNTLA) were included. Frequentist meta-analysis yielded a pooled CPA prevalence of 18% (95% confidence interval [CI], 11.6-25.4). Bayesian analysis with informative priors estimated prevalence of 7.1% (95% Credible Index, 4.5-10.4), and trim-and-fill adjustment for publication bias suggested prevalence to be 3.4% (95% CI, 0.69-7.7). On a multivariable analysis, we found CPA prevalence higher in hospital-based studies, high TB burden settings and studies with prospective or cross-sectional study designs; although CPA prevalence was higher in PTLA (23.1%) than in PNTLA (7%), it was not significantly different. We detected substantial heterogeneity (I 2 = 98.8%) and publication bias. Conclusion There is a high prevalence of CPA in patients with PMLA, particularly in TB-endemic regions and hospital settings. Patients with PMLA should be routinely screened for CPA in high prevalence settings.