RATIONALE: Allergic Bronchopulmonary Aspergillosis (ABPA) is caused by a hypersensitivity reaction to Apergillus fumigatus. Presentation includes wheezing, expectoration of brownish mucus plugs, pulmonary opacities and/or central bronchiectasis on chest imaging. ABPA in patients without previously diagnosed asthma or cystic fibrosis is a rare occurrence. Here we present an adult female with ABPA and undiagnosed asthma.
METHODS: CT scan of chest, serological evaluation, immediate hypersensitivity skin test, and methacholine challenge were performed.
RESULTS: 56-year-old woman developed dyspnea and expectoration of brownish mucus plugs. She failed multiple rounds of oral antibiotics. CT chest showed bilateral infiltrates, air trapping at the bases and dense consolidation of the left upper lobe. Subsequent bronchoscopy noted copious mucus and removal of mucus plugs. BAL showed significant fungal element, suspicious for aspergillus. Evaluation showed positive skin testing to Aspergillus fumigatus, total IgE level of 5839 IU/mL, negative aspergillus IgG. Eosinophil count peaked at 1120 cells/L. She completed 12 weeks of high dose oral steroids with symptom resolution. Follow-up CT of the chest showed complete resolution of airspace consolidation. IgE level dropped to 395 IU/mL. She sustained 3 recurrences, manifesting with IgE >2900 IU/mL and symptom recurrence. She was successfully treated with oral steroids and oral antifungal medication. Baseline pulmonary function testing was negative for obstruction or reversibility. However, methacholine challenge was positive after dose 0.25 mg/mL.
CONCLUSIONS: This is an exceptionally rare case of atypical ABPA with lack of severe asthma and/or cystic fibrosis. Diagnosis in this scenario is difficult but vital for early recognition and treatment to prevent future morbidity.
Full conference title:
- AAAAI 2019