Case presentation on Allergic Bronchopulmonary Aspergillosis

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2 : Physicion Forum Case DR. SAQIB RASHEED PGR Pulmonology Department Sheikh Zayed Hospital Rahim Yar Khan
3 : HISTROY 17 years Zuhra Saif 5-10-2010 Presenting Complaints : Fever Cough 5days SOB
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6 : D / D on X-ray Tuberculosis Pneumonia Sarcoidosis Extrinsic Allergic Alveolitis Subacute Silicosis Progressive Massive Fibrosis Ankylosing Spondylitis Radiation Pneumonitis
7 : Treatment Prescribed Wt. 39kg 20-11-2010 Tab. Rimactal INH Forte 450mg 1-OD Tab. Mymbutol 400mg 3-OD Tab. Pyrazinamide 500mg 4-OD
8 : Follow up after 2m
9 : Recurrence of symptoms 12-05-2011 Fever Cough 2weeks SOB O/E : Bil. Ronchi with crepts present all over the lung field.
10 : Follow up after 4m
11 : Possibilities of new shadows Drug resistance TB Non resolving Pneumonia ABPA Extrinsic Allergic Alveolitis Sarcoidosis Recurrent infections in Immunocompromised
12 : Start of drug resistance TB Rx Wt. 37.5kg 26-05-2011 Tab. Ethomid 250mg 1-BD Cap. Cyclosin 250mg 1-BD Tab. Quspar 100mg 2-OD Tab. Pyrazinamide 500mg 3-OD
13 : Follow up after 2m
14 : Follow up after 1 ½ Month
15 : 1st visit to us Wt. 41kg 8-09-2011 Investigation advised Rx advised : Continue the CAT-4 Rx 1 Broad spectrum antibiotic Rx of SOB on merit
16 : Investigations Advised Sputum for AFB 3OD’s Absolute Eosinophils Count Serum IgE Fresh CXR Spirometery HRCT Chest
17 : Reports No AFB seen on sputum smear examination Absolute Eosinophils Count 786 (40 – 440) Serum IgE >2000 IU / ml (20.4)
18 : Follow up after 10days
19 : HRCT Chest
20 : HRCT Chest
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25 : Spirometry
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27 : Summary Medical history : Ch.fluctuating symptoms of Fever,Cough,SOB Physical examination : Bil. Ronchi with crepts present all over lung field Investigations : Sputum for AFB 3OD’s (No AFB seen) Absolute Eosinophils Count (786) Serum IgE (>2000 IU / ml ) Fresh CXR HRCT Chest Spirometery (Mild Restriction & Moderate Obs.)
28 : Diagnosis Allergic Bronchopulmonary Aspergillosis (ABPA)
29 : Diagnostic Criteria PRIMARY CRITERIA (ARTEPICS) A – Asthma R – Radiological Fleating Pulmonary Infiltrates T – Test for A fumigatus positive on skin (immediate) E – Eosinophilia P – Precipitating Antibodies (IgE) to A. fumigatus, in 70% of cases I – IgE in serum are elevated, (Total) ? usually higher than 2500 mg/ml. C – Central Bronchiectasis, S – Serum specific IgE and IgG A. fumigatus elevate
30 : Diagnostic Criteria SECONDARY CRITERIA Expectoration of brownish sputum plugs Sputum for fungus examination Skin Testing (Late)
31 : Rx advised after diagnosing Stop CAT-4 Rx of asthma on merit with Inhaled bronchodilator and ICS Slow release Theophylin derivative Leukotriene receptor antagonist Oral Prednisolone at a dose of 30mg / day
32 : Treatment Protocols for Management of ABPA Regime 1 Prednisolone, 0.5 mg/kg/day for 1–2 wk, then on alternate days for 6–8 wk. Then taper by 5–10 mg every 2 wk and discontinue
33 : Treatment Protocols for Management of ABPA Regime 2 Prednisolone 0.75 mg/kg/day, for 6 wk then 0.5 mg/kg/day for 6 wk, Then tapered by 5 mg every 6 wk to continue for a total duration of at least 6 to 12 months.
34 : Reducing Risk Factor Environmental control measures should be ensure to maximal mould spore avoidance. Avoid damp places where fungus is more likely to grow Keep your home as dust-free as possible Dust-proof your bedding
35 : Follow-up and monitoring The patients are followed up every 6 wk with a Medical history Physical examination, Chest radiograph, and Measurement of total IgE
36 : Follow-up and Monitoring of IgE Satisfactory response : > 35% decline in IgE Doubling of baseline IgE : ABPA exacerbation. If tapering off prednisolone result in exacerbation frequently, stage IV. Prolong course of prednisone with the least possible dose. Monitor for adverse effects (eg, hypertension, secondary diabetes)
37 : Follow up after 3weeks
38 : Follow Up after 6weeks
39 : Stages of ABPA
40 : Other Rx Options Anti Fungal : Adjunctive but not primary therapy. Patient with ABPA (at any stage from 1 to 5) and is taking oral corticosteroid therapy on an ongoing basis, an antifungal may be considered as a corticosteroid-sparing agent. Itraconozole 200mg bd for 4 months Ketoconazole Voriconazole
41 : Anti IgE Rx : Omalizumab, a humanized monoclonal antibody against IgE. Administered s/c once every 2 or 4 weeks. Recurrent exacerbation Not tolarating Prednisolone Serum IgE levels high
42 : Take Home Message TB is common but not the only disease causing upper lobe shadowing. Try to prove drug resistance before jumping to 2nd line treatment. Consider referral before starting 2nd line ATT.
43 : Thank You


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Case of ABPA which was miss managed as a drug resistance TB on the basis of fleating radiological s    more
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