The first case involves a six year old girl who was apparently well until the age of six months. Thereafter, she had started developing repeated episodes of cough and cold, respiratory distress with wheezing and was hospitalised on many occasions where she was treated with antibiotics, inhaled bronchodilators and inhaled corticosteroids. Her symptoms responded only to recur again in a few weeks interval. There was no history of exposure to pets or home exposure to smokes. She was then referred to our institution for further evaluation and management for ongoing symptoms. There is no history of contact with tuberculosis.
On admission, the patient was noted to be pale, clubbed but not cyanosed with faltering weight gain (height and weight both below the 5th percentile). Examination of the chest revealed a pectus carinatum deformity (Fig. 1) and increased work of breathing (tachypneic at 32/min, bilateral wheeze and recessions). A Chest x-ray performed on admission revealed bilateral patchy opacities (Fig. 2). Her total leukocyte counts were elevated at 10,650/mm3 with 9% eosinophil in peripheral smear (absolute eosinophil count of 850/mm3). Serum IgE level was elevated at 1020 ng/mL. Sputum for acid fast tubercular bacilli and TB NAAT was negative. Flexible bronchoscopy revealed intra-bronchial mucus plugs. A high resolution chest CT scan (HRCT) showed 'tram track' bronchial dilatation and, 'tree in bud appearance' confirming bronchiectasis (Fig. 3). Her sweat chloride estimation and CFTR gene mutation (for DeltaF508) for cystic fibrosis was reported as negative. Her skin prick test to aspergillus (what reagent and what was the reading) serum IgE specific to aspergillus fumigatus were positive e. A diagnosis of ABPA was made and she was treated with oral prednisolone started at the dose of 0.75mg/kg/day over 2 week then gradually tapered over next 2 months and oral itraconazole 200 mg twice daily for 4 months. She responded favourably with progressive resolution of radiological opacities in serial chest x-rays.
Chest CT scan (HRCT) showed 'tram track' bronchial dilatation and, 'tree in bud appearance' confirming bronchiectasis.