A 33-year-old life-long asthmatic comes to the physician with 3 weeks of productive cough of thick brownish sputum, increased wheezing and dyspnea, right-sided pleuritic chest pain, chills, and fever. On occasion, his sputum is streaked with blood. He also notes fatigue and feeling "out of it." His asthma is generally managed with budesonide/formoterol inhaler, and his last exacerbation requiring steroid taper was approximately 2 months ago.
He also took prednisone 20 mg for 4 days at the onset of symptoms three weeks ago "because I had some in the house anyway." The steroids helped somewhat, but the symptoms worsened when he ran out of medication. He has had 2 previous "lung infections on the left side" with similar presentation in the past 3 years. The patient has never been intubated or admitted to an intensive care unit. He denies smoking or recent travel. He had a negative test for HIV 7 months ago.
His temperature is 38.3 C (101 F), blood pressure is 130/80 mm Hg, pulse is 70 /min, and respirations are 16 /min. Pulse oximetry shows 96% on room air. Examination shows diffuse wheezing throughout the lungs.
Laboratory results are as follows:

Chest x-ray reveals a right upper-lobe infiltrate and possible early bronchiectasis on the left side.
In addition to initiating glucocorticoid therapy, what is the next step in establishing the diagnosis?

Question

A 33-year-old life-long asthmatic comes to the physician with 3 weeks of productive cough of thick brownish sputum, increased wheezing and dyspnea, right-sided pleuritic chest pain, chills, and fever.  On occasion, his sputum is streaked with blood.  He also notes fatigue and feeling "out of it."  His asthma is generally managed with budesonide/formoterol inhaler, and his last exacerbation requiring steroid taper was approximately 2 months ago.
He also took prednisone 20 mg for 4 days at the onset of symptoms three weeks ago "because I had some in the house anyway."  The steroids helped somewhat, but the symptoms worsened when he ran out of medication.  He has had 2 previous "lung infections on the left side" with similar presentation in the past 3 years.  The patient has never been intubated or admitted to an intensive care unit.  He denies smoking or recent travel.  He had a negative test for HIV 7 months ago.
His temperature is 38.3 C (101 F), blood pressure is 130/80 mm Hg, pulse is 70 /min, and respirations are 16 /min.  Pulse oximetry shows 96% on room air.  Examination shows diffuse wheezing throughout the lungs.
Laboratory results are as follows:

Chest x-ray reveals a right upper-lobe infiltrate and possible early bronchiectasis on the left side.
In addition to initiating glucocorticoid therapy, what is the next step in establishing the diagnosis?

Quizplus · Accepted Answer

11ec193a_98d5_ab0d_853d_5118b5467159_MD0002_00 Allergic bronchopulmonary aspergillosis (ABPA) is an allergic pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus. This disorder occurs more commonly in asthmatics and cystic fibrosis patients likely due to bronchial colonization by Aspergillus. Patients may present at age 30-40 with recurrent asthma exacerbations, expectoration of dark brown mucus plugs, hemoptysis, and/or systemic symptoms (eg, fever, anorexia, malaise, or weight loss). The repeated episodes can lead to bronchial inflammation, obstruction, and mucus impaction, which progress to bronchiectasis and fibrosis. Early diagnosis is important as onset of bronchiectasis is associated with poor outcomes. A wide spectrum of radiographic changes can be seen in patients with ABPA, including fleeting pneumonias. High-resolution CT characteristically shows infiltrates, central bronchiectasis, and mucus-filled bronchi (mucoid impaction). Pulmonary function tests usually show obstructive pattern early and mixed restrictive and obstructive pattern after bronchiectasis onset. The diagnosis is suggested clinically in asthmatics, but the next step is an Aspergillus skin prick test. Immediate cutaneous hypersensitivity is a characteristic finding in ABPA and indicates likely serum A fumigatus-specific IgE antibodies. A negative skin test followed by negative intradermal reactivity to Aspergillus virtually eliminates ABPA in the differential. Other diagnostic criteria are listed in the table. Treatment involves combination of corticosteroids and antifungal agents (eg, itraconazole). (Choice B) Bronchoscopy with bronchoalveolar lavage may show Aspergillus, but the test is more invasive than skin/serological testing to diagnose ABPA. If all skin/serological tests are negative, bronchoscopy may be indicated. (Choice C) Common variable immunodeficiency (CVID) can present with recurrent pulmonary infections and bronchiectasis, but asthma is not commonly associated with CVID. This patient's lung infiltrates are more likely due to ABPA. (Choice D) Induced sputum for Pneumocystis jiroveci may be helpful to diagnose Pneumocystis pneumonia in an asthmatic taking high-dose chronic oral steroids. However, this patient was only on intermittent steroids. (Choice E) QuantiFERON-TB Gold is useful for diagnosing latent tuberculosis and has a higher specificity than tuberculin skin testing. However, the clinical scenario described, including the upper-lung infiltrate, is classic for ABPA. Educational objective: Allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to Aspergillus that occurs in the airways of patients with asthma and cystic fibrosis. It presents with worsening asthma symptoms, fevers, fleeting infiltrates, pleuritic chest pain, and peripheral eosinophilia. The first step in diagnosis is Aspergillus skin testing. If left untreated, the disorder can result in bronchiectasis with a poor prognosis. __________ References: Allergic bronchopulmonary aspergillosis. (http://www.ncbi.nlm.nih.gov/pubmed/19265090)

A 33-Year-Old Life-Long Asthmatic Comes to the Physician with 3