A 41-year-old male with bronchiectasis, chronic sinusitis, and obstructive lung disease presented to the emergency department in acute on chronic hypoxic respiratory failure. Chart review showed multiple encounters for shortness of breath and cough, with increasing admission frequency over the preceding 2 months. On each occasion he was given a diagnosis of COPD exacerbation and treated with steroids and azithromycin or doxycycline. Symptoms between admissions were poorly controlled despite adherence to albuterol, montelukast, and ranitidine. The patient initially noted dyspnea 12 years prior and had been on 2.5 L/minute home oxygen for the preceding 8 years. The patient reported dyspnea unrelated to exertion and dry cough. Over the last few months, patient denied remission of symptoms and had no history of atopy. Patient admitted night sweats, chills, and a 4.5-kg. unintentional weight loss with suspected exposure to tuberculosis while imprisoned. Patient declared a 5-pack year smoking history with quit date 10 years prior to admission and denied alcohol and illicit drug use. Prior to incarceration the patient worked at a fertilizer factory. Family history and surgical history were non-contributory.
On examination, the patient was afebrile with normal vital signs. The patient was a thin white male in respiratory distress with prolonged expiratory phase, diffuse expiratory wheeze and cough. No crackles were heard, and the patient did not exhibit clubbing.
A pulmonary function test administered 6 years before presentation demonstrated reduced flow and capacity with mid flow-loop obstruction, which was responsive to bronchodilator, and mildly reduced diffusion capacity. Previous results also included a normal alpha-1 antitrypsin level and a non-diagnostic bronchial alveolar lavage (BAL) that disclosed moderate polymorphonuclear neutrophils with normal respiratory flora.
Laboratory testing revealed a white blood cell count of 11.75 K/muL comprised of 93% neutrophils but also an eosinophil count of 0.04 K/muL. The complete metabolic panel was normal.
A chest radiograph showed no acute pulmonary radiologic findings (Fig. 1). Due to chronic course and relapses, the pulmonology team performed flexible fiberoptic bronchoscopy with BAL from the right middle lobe of lung. BAL cytology resulted with eosinophilia but microbiology stains, PCRs and cultures were negative.
Computed-tomography (CT) showed mild centrilobar emphysema with a few subpleural blebs in the right upper lung and signs of central bronchiectasis. Also, there was minimal apical scarring bilaterally (Fig. 2).
The serum specific IgE against A. fumigatus was positive (4.23 kU/L) and serum total IgE (3868 kU/L) was markedly elevated. Serum precipitins (specific IgG) against Aspergillus spp. were negative. A. fumigatus and A. terreus by PCR and fungal blood cultures were negative. Table 1 below summarizes the findings in our case and how the findings differ from the minimum essential diagnostic criteria proposed by Greenberger.
A diagnosis of ABPA was made as our case met three of the minimum essential criteria despite not performing a skin prick test and a negative history of asthma. The patient was treated with itraconazole and prednisone. On follow up, the patient reported improvement of cough, sputum, and dyspnea.
CT of the chest showed mild centrilobar emphysema with a few subpleural blebs in the right upper lung and signs of central bronchiectasis.