allergic bronchopulmonary aspergillosis

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INTERESTING CASE ABPA IN HEALTHY INDIVIDUAL NNR UNIT Dr. Sunil Pawar KEM HOSPITAL PAREL MUMBAI

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HISTORY 26 yr old healthy male Occ alcoholic, smoker, tobacco chewer Symptomatic since 15 days cough with scanty mucoid expectoration breathlessness chest tightness fever with mild chills symptoms progressive

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HISTORY Cntd… No h/o hemoptysis, chest pain, No h/o palpitations, PND, No h/o calf swelling & pain No h/o loose motions,bloating,indigestion,worms in stool No h/o drug/ayu med ingestion No h/o similar complaints in past No h/o kochs/kochs contact

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EXAMINATION Pulse – 88/min reg Blood pressure – 118/76 mm Hg LN/Pallor/c/ict/edema – Absent RS – b/l wheezes all over lung fields CVS – WNL PA – WNL CNS – WNL

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INVESTIGATIONS

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D/D ASTHMATIC FEATURES WITH EOSINOPHILIA- Loeffler’s syndrome Acute eosinophilic pneumonia Parasitic infestations Churg strauss syndrome Allergic bronchopulmonary mycosis

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t/t started Hetrazan Steroids albendazole

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URINE R/M – Normal no rbc/casts STOOL R/M thrice – no worms/cysts HIV ELISA/HBsAg/Anti HCV – neg FBS/PLBS - Normal ANA/ANCA – Neg Sr total IgE levels – 24887 IU/ml (1.5-378 IU/ml) HRCT Chest – central bronchiectasis

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Sr IgE specific for A.fumigatus- 1.67(< 0.1 ku/ml)

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FINAL DIAGNOSIS Asthmatic clinical features Eosinophilia Central bronchiectasis Raised total as well as aspergillus specific IgE antibodies ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS

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TREATMENT T.Prednisolone 1mg/kg for 1 month followed by tapering 5mg/wk T.Itraconazole 200 mg/d od for 28 days and stop.

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D/D ASTHMATIC FEATURES WITH EOSINOPHILIA- ETIOLOGY KNOWN- Allergic bronchopulmonary mycosis Parasitic infestations Drug reaction sulpho/nitrofurantoin/peni/inh/indomethcin/thiazide Eosinophilia myalgia syndrome IDIOPATHIC – Loeffler’s syndrome Acute eosinophilic pneumonia Chronic eosinophilic pneumonia Churg strauss syndrome Hyper eosinophilic syndrome

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The clinical spectrum of conditions resulting from inhalation of aspergillus spores. Zmeili O , Soubani A QJM 2007;100:317-334 © The Author 2007. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

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ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS

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It is estimated that 7–14% of corticosteroid-dependent asthmatics and 6% of patients with cystic fibrosis develop ABPA. Few case reports of aspergillosis affecting healthy persons. clinical presentation - asthma and episodic wheezing, - expectoration of sputum containing brown plugs, - pleuritic chest pain, and fever. Subdivided in two groups: - with central bronchiectasis (ABPA-CB) - without central bronchiectasis (ABPA- seropositive) Polat G, Urpek G, Yilmaz U, Büyüksirin M, Karadag Polat S, Uluer S, Tibet G. Successful treatment of invasive pulmonary aspergillosis in an immunocompetent host. Respirology. 2005 Jun;10(3):393-5.

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PATHOLOGY Allergy to the spores of Aspergillus moulds. Affects asthma,cystic fibrosis and bronchiectasis patients. The fungus takes up residence in the lungs and grows in the air spaces deep within. Non-invasive but source of allergic reaction. A.shoemark,l.ozerovitch,r.wilson; Aetiology in adult patients with bronchiectasis;Respiratory medicine (2007)101,1163-1170

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STAGES

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CXR and CT features – Pulmonary infiltrates 'ring sign' and 'tram lines' - inflamed bronchi transient areas of opacification due to mucoid impaction of the airways, which may present as band-like opacities emanating from the hilum with rounded distal margin (gloved finger appearance). Central bronchiectasis and pulmonary fibrosis Chest CT scan better for defining bronchiectasis

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TREATMENT Corticosteroids relief of bronchospasm, the resolution of radiographic infiltrates the reduction in serum total IgE and peripheral eosinophilia. duration of therapy-individualized till symptom resolves. on recurrence repeat steroids course should be given. Inhaled corticosteroids fail to prevent the progression of lung damage in patients with ABPA.

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ITRACONAZOLE (200-400 mg/day) for 28 days. Its absorption dependent on acid environment in stomach and should be taken with orange juice and food. Total serum IgE serves as a marker of ABPA disease activity, and should be checked 6–8 weeks after the initiation of therapy, then every 8 weeks for 1 year to determine a baseline range for each individual patient. the anti-IgE monoclonal antibody omalizumab (Xolair) ,inhaled amphotericin B has been described beneficial in patients with ABPA Hayes D Jr, Murphy BS, Lynch JE, Feola DJ. Aerosolized amphotericin for thetreatment of allergic bronchopulmonary aspergillosis. Pediatr Pulmonol. 2010 Nov;45(11):1145-8. Patrick Lebecque, A Leonard, M Argaz, Véronique Godding, Charles Pilette; Omalizumab for exacerbations of allergic bronchopulmonary aspergillosis in patients with cystic fibrosis; BMJ Case Reports 2009; doi:10.1136/bcr.07.2008.0379

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Thank you

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allergic brochopulmonary aspergillosis ina acute form without predisposing condition of asthma
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