Case 061: Severe asthma with Fungal Sensitisation
Summary:

A 41-year-old lady is diagnosed with asthma.  Four years later her symptoms rapidly worsen after camping outside in a damp tent.  Two years following this, her symptoms remain florid giving her the label of severe asthma and requiring almost continuous steroids.  A further two years pass and blood tests lead to a diagnosis of presumed ABPA.  Short-term treatment with oral itraconazole fails due to the concomitant use of lansoprazole (decreasing the absorption of the antifungal).  She remains unwell.  A move from the Midlands to the North West precipitates a review of both her symptomatology and her diagnoses.  A negative serum Aspergillus precipitins with a total IgE level of 470 KIU/l (Aspergillus fumigatus specific IgE 4.7 KUa/l) suggests a diagnosis of SAFS (Severe Asthma with Fungal Sensitisation) rather than ABPA.  A higher dose of oral itraconazole is commenced.  Over the subsequent eighteen months her symptoms improve dramatically.

Comments:

Diagnosis:
The cardinal feature of ABPA is a serum IgE of >1,000 KIU/L and usually this is accompanied by positive Aspergillus precipitins and either a positive Aspergillus RAST test or skin prick test. Only the Aspergillus RAST met these criteria in this patient. We do not have historical information on eosinophilia (which may be found in ABPA and SAFS) and is usually not present of oral steroids are administered. She did describe coughing up plugs, which is typical of ABPA, but no features of episodic infiltrates, which is often a feature of ABPA. Her CT scan of the chest was not consistent with ABPA. She fits the diagnostic criteria for SAFS perfectly.

Response to antifungal therapy:
Following the initial diagnosis of ABPA, treatment was commenced with oral itraconazole 100 mg od. This is a sub-therapeutic dose. In addition, she was already on long-term lansoprazole, which continued throughout the antifungal treatment.  Lansoprazole is known to decrease the absorption of itraconazole; consequently her symptoms showed no improvement.  Later therapy with 200 mg bd itraconazole (with continued lansoprazole) gave the required results, as this higher dose compensates for the decreased absorption.  Two months later her serum itraconazole level was high at 18.5 mg/l, precipitating a reduction in her dose to 150 mg bd which gives the required serum levels and sustained symptomatic improvement.

Outcome:
This lady’s symptomatology dramatically improved following antifungal treatment.  Two weeks after commencement of treatment she had no cough or wheeze, and at four weeks rarely requires the use of her salbutamol inhaler.  Over the following eighteen months she has significantly less hospital admissions and rarely requires oral steroids.  Her quality of life is incomparably better compared to that before antifungal treatment.