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It is characterized by progressive extrahepatic bile duct obstruction in young infants. Inspired by the success of antifungal treatment in a newborn with BA-related obstructive cholangitis, we explored a potential link between BA and fungi, particularly\n                      <jats:italic>Aspergillus<\/jats:italic>\n                      . Fecal DNA was analyzed using 18S ribosomal sequencing and validated with a published fecal metagenomic dataset. Epidemiological data from the UK, Taiwan, and Japan were also examined.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Gut\n                      <jats:italic>Aspergillus<\/jats:italic>\n                      was exclusively detected in BA cases, suggesting it may be a potential trigger. Independent fecal metagenomic data from China and epidemiological correlations further supported this hypothesis. In the UK, BA presentations strongly correlated (\n                      <jats:italic>r<\/jats:italic>\n                      = 0.98, 95% CI [0.36, 1.0],\n                      <jats:italic>p<\/jats:italic>\n                      = 0.02) with\n                      <jats:italic>Aspergillosis<\/jats:italic>\n                      , but not with\n                      <jats:italic>Candidiasis<\/jats:italic>\n                      , during the COVID-19 lockdown. In Taiwan, a decade of data showed BA incidence was significantly associated (\n                      <jats:italic>r<\/jats:italic>\n                      = 0.78, 95% CI [0.29, 0.94],\n                      <jats:italic>p<\/jats:italic>\n                      = 0.01) with yearly\n                      <jats:italic>Aspergillus<\/jats:italic>\n                      -positive isolates among cancer-adjusted hospital admissions. In Japan, BA cases over 25 years correlated significantly (\n                      <jats:italic>r<\/jats:italic>\n                      = 0.85, 95% CI [0.37, 0.97],\n                      <jats:italic>p<\/jats:italic>\n                      = 0.01) with visceral\n                      <jats:italic>Aspergillus<\/jats:italic>\n                      burdens in autopsied cases, but not with other fungal infections.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\n                      The resolution of obstructive cholangitis in the antifungal-treated index case, together with multi-modal, cross-country evidence, highlights a potential link between gut\n                      <jats:italic>Aspergillus<\/jats:italic>\n                      and BA. Although limited by small sample size, retrospective design, and lack of mechanistic validation, the study may still be interpreted as hypothesis-generating and underscores the need for prospective studies to validate and extend these observations.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s13099-025-00772-7","type":"journal-article","created":{"date-parts":[[2025,11,17]],"date-time":"2025-11-17T06:58:31Z","timestamp":1763362711000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cross-country multi-modal evidence links Aspergillus to biliary atresia"],"prefix":"10.1186","volume":"17","author":[{"given":"Song-Wei","family":"Huang","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chia-Ray","family":"Lin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ya-Hui","family":"Chang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yen-Hsuan","family":"Ni","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Huey-Ling","family":"Chen","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hong-Hsing","family":"Liu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2025,11,17]]},"reference":[{"issue":"5","key":"772_CR1","doi-asserted-by":"publisher","first-page":"1724","DOI":"10.1002\/hep.26512","volume":"58","author":"KB Schwarz","year":"2013","unstructured":"Schwarz KB, Haber BH, Rosenthal P, Mack CL, Moore J, Bove K, et al. 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Written informed consent was obtained from the parents or legal guardians of all participating children.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"During manuscript preparation, the authors used ChatGPT to enhance readability. After applying this tool, the authors reviewed and edited the content as needed and take full responsibility for the final manuscript.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Generative AI and AI-assisted technologies in the writing process"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"94"}}