Allergic bronchopulmonary aspergillosis misdiagnosed as recurrent pneumonia in a child: a case report

Author:

Jiang NN; Li X

Author address:

Allergy Department, Beijing Children’s Hospital, Beijing, China

Full conference title:

European Academy of Allergy and Clinical Immunology Congress 2017

Abstract:

Case Report Introduction: Allergic bronchopulmonary aspergillosis (ABPA) is an allergic lung disease usually caused by Aspergillus fumigatus, which characterized by wheeze, productive cough and pulmonary infiltrates associated with a decline in lung function. The prevalence of ABPA is estimated to be approximately 1–2% in adult patients with asthma and 2–15% in patients with cystic fibrosis (CF). In children, the incidence of ABPA is unknown. Here we report the case of a 13-year old girl with ABPA who presented with recurrent pneumonia.

Case Report: A 13 year old girl referred to our hospital with a 15 months history of productive cough and 4 months of intermittent wheezing. Fifteen months ago, she complained of cough and occasionally cough up purulent sputum, then she was admitted to local hospital, her chest X ray showed opacities, she was diagnosed pneumonia and treated with cephalosporin for 8 days and discharged after cough improving. However, she still suffered from intermittent cough after discharge,and symptoms were aggravated after exercise or cold. Nine months ago, her suffered productive cough and increased thick sputum, combined with fever, she was admitted to the local hospital again, the routine blood test showed WBC 6.53 9 109 /L, N 43.2%, L 40.6%, E 7.7%, CRP 6 mg/L, her chest X ray still showed opacities, and she treated as pneumonia using azithromycin and cephalosporin, her symptoms slightly improved. Eight months ago, her symptoms were exacerbated after cold, and purulent sputum occasionally contained brown particle, the routine blood test showed WBC 7.59 9 109 /L, N 55.3%, L 36.5%, E 3.6%, CRP 0.5 mg/L, her chest X ray showed multiple opacities in left lung, she was diagnosed mycoplasmal pneumonia and received treatment by azithromycin (3 courses), her symptoms had slight remission. Four months ago, her experienced wheezing, short of breath and chest tightness when she travelled abroad, the symptoms relieved after oral glucocorticoid and in the following months she often felt short of breath especially after exercise and gradually exercise intolerance. One months ago, her symptoms got worse after upper airway infection, she presented productive cough, wheezing and expectorated an amount of brown black sputum, and referred to local hospital, the routine blood test showed WBC 10.06 9 109 /L, N 60.2%, L23.3%, E 10.51%, CRP 6.9 mg/L, Total IgE >3000 IU/mL, pulmonary function test showed mild restrictive ventilatory functional disturbance (FEV1: forced expiratory volume in one second 67.3% predicted), bronchial dilation test (+), chest X ray showed right upper lung opacities, she was still treated as pneumonia and received cephalosporin with no obvious improvement. Then she referred to our hospital, further investigation was done and the laboratory results were as follows: total immunoglobulin E and serum IgE were both detected using ImmunoCAP system (Phadia, Uppsala, Sweden). total IgE was 25180 kU/L (positive,>60KU/L), Aspergillus-specific IgE was 34.7 kUA/L (positive, >0.35 kUA/L). other positive allergens included: dust mite, chest high-resolution computed tomography (HRCT) showed infiltration、central bronchiectasis and high-attenuation mucus in the left lower lobe and lingula. On bronchoscopy a large amount of purulent material and brownish sputum plugs within the posterior and anterior segment of the right upper lobe、anterior basal segment of right lower lobe and lingual segment airways were seen. (Figure) Bronchiectasis was seen in anterior segment of right upper lobe and anterior basal segment of right lower lobe. Aspergillus fumigatus were cultured from bronchoalveolar lavage (BAL) and sputum. Tests for other possible pathogens including: cultures and/or stains of blood and sputum for viruses, mycoplasma pneumoniae,fungi (G and GM test), bacteria were negative. All autoimmune antibodies (ANAs, ENA, dsDNA, ANCA)were negative. The diagnosis of ABPA was considered. Corticosteroid (prednisone 0.5 mg/kg/day) plus itraconazole (200 mg, twice a day) was initiated. The girl responded well to the therapy. Two weeks later, she was free of symptoms. Lung function nearly improved to normal. One month later, her condition stabilized. Peripheral eosinophil percentage and IgE decreased to 1% and 404 IU/L, respectively. Chest CT showed improvement in pulmonary infiltration.

Conclusion: The present case emphasizes the importance of considering the diagnosis of ABPA in children with uncontrolled pneumonia, hypereosinophilia, and bronchiectasis. Early diagnosis and initiation of systemic corticosteroids are essential to prevent irreversible damage.

Abstract Number: 1221

Conference Year: 2017

Link Conference abstract: 

EAACI 2017

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