A 28-year-old nonsmoker, male office worker, presented with persistent cough with scanty, mucoid expectoration and gradually progressive breathlessness for last two years. There was no diurnal or seasonal variation of cough or breathlessness. History of intermittent fever along with increased severity of symptoms was present. Past history revealed that since childhood he was suffering from recurrent cough and cold, nasal itching, and obstruction, especially in summer. No history of food or drug allergy and atopic dermatitis were revealed. Family history of asthma or atopy was not documented. Past history of tuberculosis was not present. He complained of retrosternal burning sensation, especially at night. Spirometry before presenting to us revealed obstructive ventilatory defect with partial reversibility to bronchodilator. Therefore, the patient was diagnosed as having asthma and medium dose ICS plus inhaled LABA was advised. Despite adequate compliance and correct inhaler technique, his asthma was uncontrolled; inhaled salbutamol was taken more than twice a week.
On general survey at presentation, only mild pallor was seen. His respiratory rate was 24 breaths/minute, and pulse rate 120 beats/minutes. Examination of the respiratory system revealed barrel shaped chest. There were bilateral hyperresonant percussion note, diminished vesicular breath sound, and bilateral crackles with occasional wheezing.
Absolute eosinophil count was 1,500/cmm. Sputum smear for acid fast bacilli and sputum culture for Mycobacterium tuberculosis were negative. Chest X - ray (CXR), posteroanterior view showed bilateral hyperinflated lung with reticular shadows. Spirometry in our institution showed mixed pattern with partial reversibility to inhaled salbutamol, although his effort was not adequate. The patient was advised high dose ICS, inhaled LABA, and once daily 10 mg montelukast, and the treatment was gradually stepped up by addition once daily 400 mg sustained release theophylline within two months, as his symptoms were not under control. We also advised once daily 40 mg esomeprazole and 30 mg sustained release domperidone, and once daily mometasone nasal spray (two sprays in each nostril). But our all efforts were in vain. High resolution computed tomogram (HRCT) of thorax revealed bilateral reticulonodular pattern with patchy consolodation [Figure 1]. Further investigations showed total serum immunoglobulin E (IgE) level was 1979.1 U/L and Aspergillus fumigatus specific serum IgE was positive (1.39 U/L). Skin prick test with aspergillin antigen was positive. From these, the diagnosis of ABPA was suggested, although diagnosis was confused with diffuse parenchymal lung disease (DPLD) due to atypical presentation and HRCT pattern. Bronchoalveolar lavage fluid analysis showed only eosinophila. Oral prednisolone at dose of 0.5 mg/kg/day along with oral itraconazole 200 mg twice daily was added. Patient gradually improved within one month. Follow up CXR and spirometry showed significant improvement after six weeks. Oral prednisolone after six weeks was tapered off at the rate of 5 mg/week over six weeks. Total duration of oral prednisolone was planned for six months. Itraconazole was continued as 200 mg twice daily for eight weeks, then 200 mg once daily for another eight weeks. On six month follow up, his asthmatic symptoms were well controlled, and CXR was normal.