To Treat with Steroids or Not to Treat: That Is the Question

P. Agarwal1, J. Sunderram2

Author address: 

1Pulm critical care, Robert Wood Johnson Medical School, New Brunswick, NJ, United States, 2Div of Pulm Med, Rutgers Robert Wood Johnson Med Sch, New Brunswick, NJ, United States.

Abstract: 

Introduction: Depending upon the immune status of the patient, Aspergillus can produce a wide spectrum of diseases from aspergillomas in old cavities in immunocompetent hosts to chronic cavitary aspergillosis (CCA) in the mildly immunocompromised to invasive aspergillosis in the severely immunocompromised host and as allergic bronchopulmonary aspergillosis (ABPA) in the hypersensitive host. We discuss a patient who demonstrated two aspects of the disease spectrum simultaneously presenting a treatment dilemma. Case: A 62 y/o female from Peru with a history of asthma and TB treated for 9 months several years prior presented with worsening productive cough and no reported hemoptysis. Three months prior to presentation, she had been treated for pneumonia due to an abnormal Computer Tomography (CT) scan of the chest. Tuberculosis was ruled out and she was discharged on antibiotics. She however, presented to the emergency room with persistent cough, worsening shortness of breath on exertion, fatigue, and weight loss. She denied any fever or chest pain. On exam she appeared mildly dyspneic and had significant wheezing. On admission a CT scan of the chest showed multifocal cavitation in the right upper lung with thickening of cavity wall measuring 8 mm. There was a 1.7 cm lobulated density within the cavity consistent with an aspergilloma. Patchy multifocal nodularity with tree-in-bud opacities were also seen throughout both lung fields. Repeat sputum acid fast bacillus (AFB) was negative. Her differential cell count showed eosinophilia (Absolute count of 970/µl). The total IgE (2583 IU/ml) and the aspergillus specific IgE (2.96 KU/L) and IgG (166 mg/L) were also elevated. However, her serum galactomannan assay was negative. Due to these findings, the patient met criteria for both CCA and ABPA. Discussion: While antifungal therapy is used in CCA, steroids are the first line of choice for ABPA. However, treatment with steroids carries a risk of progression to invasive aspergillosis in a patient with CCA. Due to the rarity of her clinical presentation of CCA and ABPA, no clear therapeutic guidelines are available. The patient was started on antifungal therapy with a plan to initiate treatment with prednisone in a month’s time. She will be followed closely with appropriate lab work-up and imaging. Serum galactomannan will be specifically monitored, as its rise is indicative of active invasion. This case is unique for a single patient with the disease manifestation of both a hypersensitive and immunocompromised host and for the dilemma this presents in treatment.

Tables: 

2018

abstract No: 

A5417 / P1195

Full conference title: 

The American Thoracic Society Conference 2018
    • ATS 2018