A 64-year-old male with a history of moderate persistent asthma and long-standing interstitial lung disease (ILD) classified several years ago as bronchiolitis obliterans with organizing pneumonia (BOOP) presented to general pulmonary clinic with a progressively worsening cough and sputum production. Recently he had been increasing use of his albuterol rescue inhaler to multiple times daily. He previously carried the diagnosis of BOOP from an outside hospital in 1992 incidentally noted on CXR imaging. He was additionally found to be purified protein derivative (PPD) positive at that time and treated with isoniazid for 6 months for latent tuberculosis. He was followed with serial pulmonary function testing and imaging noting stable disease for years prior to establishing care at our clinic. He had an extensive travel history to several African countries. An HRCT of his chest showed diffuse peribronchovascular consolidations with basilar and peripheral predominance, and diffuse perivascular calcifications (Fig. 1, Fig. 2, Fig. 3, Fig. 4). His right lower lobe showed subpleural scarring, and his left lower lobe showed bronchial obstruction with distal reconstitution. Serologic work-up was negative for autoimmune conditions, immunodeficiencies, chronic infections, and cystic fibrosis. Absolute eosinophils were noted to be 1168 cells/uL on complete blood count with differential (CBC). Serum IgE was elevated at 1133 kU/L, with positive IgE for Aspergillus fumigatus at 6.12 kU/L. He was diagnosed with allergic bronchopulmonary aspergillosis (ABPA) and started on treatment with two weeks of prednisone 30mg oral daily followed by a six month prolonged taper. Following this taper, the patient reported significant symptomatic improvement and continued his maintenance treatment for asthma and airway clearance. Later surveillance imaging after treatment did not show any significant change in his imaging findings. Serum IgE downtrended to 167 kU/L and peripheral eosinophils decreased to 377 cell/uL with steroid treatment.
Transverse slice of a high resolution computed tomographic scan of the chest on inspiration with thin slices using lung windowing demonstrating both the bilateral pulmonary opacities, calcifications, and mild bronchiectasis throughout the bilateral lower lobes of the lungs.