Post-tuberculosis lung disease and pulmonary aspergillosis management: challenges and considerations.

INTRODUCTION: Post-tuberculosis lung abnormality (PTLA) affects over 50-140 million TB survivors globally, creating a highly permissive environment for secondary fungal disease, particularly chronic pulmonary aspergillosis (CPA). CPA is now recognized as the most frequent and clinically significant-related complication of PTLA, contributing substantially to respiratory morbidity, misdiagnosis as TB relapse, and excess mortality in high TB-burden regions. Despite this, CPA remains largely absent from post-TB care pathways.

AREAS COVERED: This review synthesizes current evidence on CPA complicating PTLA, including epidemiology, pathogenesis, diagnosis, and management. Key findings include CPA prevalence of 7-23% in TB survivors, diagnostic utility of automated-IgG assays, and characteristic chest CT-features. Randomized trials demonstrate the superiority of 12-month itraconazole, comparative efficacy of itraconazole and voriconazole, and the emerging role of posaconazole, isavuconazole, and nebulized amphotericin B are summarized. Field- and hospital-based diagnostic algorithms, refined treatment response criteria, and gaps in biomarker monitoring are addressed.

EXPERT OPINION: CPA remains severely underdiagnosed due to overlapping features with TB, limited diagnostic access, and absence from national TB programs. Integrating CPA diagnostic bundles into national TB programs, standardizing serologic thresholds, ensuring antifungal stewardship, and developing validated composite response criteria are essential to improving outcomes in PTLA populations.