Asthma Masquerader Uncovered by Bronchoscopic Transbronchial Cryobiopsy

O. Kalchiem-Dekel, L. Parker, A. B. Sagar, J. R. Galvin, N. W. Todd, E. M. Pickering, A. Sachdeva;

Author address: 

University of Maryland School of Medicine, Baltimore, MD, United States.


Introduction: Up to one third of adults carrying a diagnosis of asthma are either misdiagnosed or harbor additional conditions contributing to their respiratory symptoms, such as heart failure, laryngopharyngeal reflux, and inducible laryngeal obstruction. Moreover, asthma can be mimicked or complicated by eosinophilic conditions such as allergic bronchopulmonary mycosis (ABPM), aspirin-exacerbated respiratory disease, eosinophilic granulomatosis and polyangiitis (EGPA), and chronic eosinophilic pneumonia (CEP). 
Case Presentation: A 69-years old never-smoker man was referred for evaluation of 12-month history of wheezing and dyspnea. His symptoms persisted despite treatment with high-dose inhaled corticosteroids and a long-acting beta agonist. Pulmonary function tests revealed moderate obstruction (FEV1=1.89L, 64% predicted; FVC=3.66L, 83% predicted) with a significant bronchodilator response (post-bronchodilator FVC=4.28L; post bronchodilator FEV1=2.63L), and mild diffusion defect (DLco=17.3 mL/mmHg/min, 74% predicted). Peripheral blood eosinophilia of 1,500 cells/uL (norm: <300) was noted. IgE was also elevated at 236 kU/L (norm: 0-114). Proteinase 3 and myeloperoxidase antibodies were negative as were serum Aspergillus antigen, IgG, and IgE. Chest computerized tomography revealed subtle bilateral ill-defined nodularity and ground glass opacities in a subpleural and upper lobe distribution (Figure). Bronchoscopic transbronchial cryobiopsy obtained from the right lung revealed infiltration of alveolar parenchyma and bronchial walls with numerous eosinophils (Figure). Subsequent bone marrow biopsy was normocellular with normal trilineage hematopoiesis, establishing the diagnosis of CEP. The patient was started on oral corticosteroids with slow tapering, which resulted in complete resolution of symptoms and normalization of peripheral blood eosinophil count. 
Discussion: We present a patient with treatment-resistant wheezing diagnosed with CEP by cryobiopsy, facilitating a clinical-radiologic-pathologic discussion. Eosinophilic pulmonary disease, such as CEP, ABPM, and EGPA can masquerade as asthma or overlap with it and should be considered in a patient with treatment-resistant obstructive respiratory disease and peripheral blood eosinophilia. Cryobiopsy is increasingly recognized as a valuable tool in the evaluation of patients with interstitial lung disease and has a diagnostic yield approaching that of surgical lung biopsy when combined with a multidisciplinary team discussion. This case is unique in that the imaging findings were not classic for CEP and the diagnosis was established by cryobiopsy. Data supporting the utility of cryobiopsy in the diagnosis CEP are scarce. We hypothesize that larger tissue sample and lack of crash artefact provided by crybiopsy are likely to improve confidence in achieving a diagnosis; however, higher procedural risks such as pneumothorax and bleeding, must be taken into consideration.

abstract No: 

A6474 / P852

Full conference title: 

The American Thoracic Society Conference 2018
    • ATS 2018