This week is not only pulmonary week, it is asthma week.
The CXR and CT shown above are from a patient referred to you because she has asthma that just won't go away. She is 30, but she had asthma since she was a child. Every year, she gets a few exacerbations with bronchial obstruction, fever, malaise, cough productive of brown mucous plugs, and occasional hemoptysis. Her blood counts always show peripheral eosinophilia. Wheezing is present. These episodes are only minimally responsive to bronchodilators such as albuterol and ipratropium, but they respond well to systemic steroids. Pulmonary function tests show airflow obstruction, air trapping with a reduced FEV1, and increased residual volume. Improvement is minimal with a bronchodilator. A skin test shows reactivity to Aspergillus antigens, serum antibodies against Aspergillus are positive, and serum total IgE is elevated >1000 ng/mL.Challenge: The referring doctor asks what antibiotics he should use for this infection?
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Asthma I
This is allergic bronchopulmonary aspergillosis, a complex hypersensitivity reaction seen in patients with asthma or cystic fibrosis. The pathophysiology is unknown, but it is colonization and not infection of the bronchi by Aspergillus that leads to obstruction, inflammation, mucoid impaction, bronchiectasis, and fibrosis. The CXR shows bronchial wall thickening and central bronchiectasis. The CT shows varicoid and cystic central bronchiectasis. Treatment is with glucocorticoids and intraconazole.
Sources: UpToDate; uchsc.edu.
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