ABPA and mucoid impaction

74 year old woman, known to have ABPA without asthma, bronchiectasis and oesophagitis and reflux. Presented originally age 68 years and improved with itraconazole. This was stopped and she continued on daily hypertonic saline nebulisers, with continuing cough. 
Relapsed with chronic cough and increasing breathlessness. She had a trachea deviated to the left and silent breath sounds in the left upper zone and left base. A bronchoscopy showed mucoid impaction and complete occlusion of the left upper and left lower lobes with thick mucus. This was removed with saline and suction, and distally the airways were normal. Her total and Aspergillus specific IgE had risen from 1100 kU/L and 13.0 kAU/L in August 2015 to 5100 kU/l and 21.6 kAU/L in November 2015. Her Aspergillus IgG also rose from 44mg/L to 102 mg/L over the same period.
She continued on prednisolone and itraconazole was restarted. She improved and her chest Xray abnormalities resolved.

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