A 38-year-old woman comes to the office due to worsening asthma symptoms for 2-3 days. She has shortness of breath, wheezing, and productive cough. The patient describes thick sputum that was blood-tinged yesterday. She was diagnosed with asthma 12 years ago but says that it had not been this bad until last year. For the past year the patient has had 2 hospitalizations for asthma exacerbations but has never been intubated. She completed a course of oral prednisone and azithromycin 2 months ago. Current medications include a daily fluticasone inhaler and as-needed albuterol inhaler. The patient reports no decrease in appetite or weight loss and has not travelled outside of her home state of New Jersey in the past 2 years. She works as a school teacher and does not use tobacco, alcohol, or illicit drugs. The patient has no second-hand tobacco exposure and no known allergies. Her grandmother also has asthma. Temperature is 37 C (98.6 F), blood pressure is 123/80 mm Hg, pulse is 94/min, and respirations are 16/min. Pulse oximetry shows 95% on room air. Pulmonary examination reveals scattered wheezes. Heart sounds are normal. There is no clubbing, peripheral edema, or skin rashes. Complete blood count shows the following: Chest x-ray reveals patchy bilateral upper lobe infiltrates and prominent bronchial markings. Which of the following is the best next step in diagnosing the cause of this patient's worsening symptoms?

Question

A 38-year-old woman comes to the office due to worsening asthma symptoms for 2-3 days.  She has shortness of breath, wheezing, and productive cough.  The patient describes thick sputum that was blood-tinged yesterday.  She was diagnosed with asthma 12 years ago but says that it had not been this bad until last year.  For the past year the patient has had 2 hospitalizations for asthma exacerbations but has never been intubated.  She completed a course of oral prednisone and azithromycin 2 months ago.  Current medications include a daily fluticasone inhaler and as-needed albuterol inhaler.  The patient reports no decrease in appetite or weight loss and has not travelled outside of her home state of New Jersey in the past 2 years.  She works as a school teacher and does not use tobacco, alcohol, or illicit drugs.  The patient has no second-hand tobacco exposure and no known allergies.  Her grandmother also has asthma.  Temperature is 37 C (98.6 F), blood pressure is 123/80 mm Hg, pulse is 94/min, and respirations are 16/min.  Pulse oximetry shows 95% on room air.  Pulmonary examination reveals scattered wheezes.  Heart sounds are normal.  There is no clubbing, peripheral edema, or skin rashes.  Complete blood count shows the following:  Chest x-ray reveals patchy bilateral upper lobe infiltrates and prominent bronchial markings.  Which of the following is the best next step in diagnosing the cause of this patient's worsening symptoms?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c072_0132_8f63_cd533f6aaccc_MD0005_00 This patient is most likely suffering from allergic bronchopulmonary aspergillosis (ABPA). ABPA occurs when patients with either underlying asthma or cystic fibrosis become sensitized to Aspergillus antigens, resulting in an intense IgE- and IgG-mediated immune response. It should be suspected any time a patient with one of these preexisting conditions develops recurrent exacerbations with fever, malaise, cough with brownish mucoid sputum, wheezing, or symptoms of bronchial obstruction. Current diagnostic criteria for ABPA include an elevated Aspergillus-specific IgE with an elevated (eg, >417 IU/mL) total IgE, positive Aspergillus-specific IgG, eosinophilia, and positive skin test reactivity for Aspergillus. Consequently, the initial evaluation for ABPA should include either skin testing for Aspergillus or analysis of total and specific IgE concentrations. Chest radiography typically demonstrates upper lobe opacities, atelectasis due to mucus plugging, and signs of bronchiectasis such as bronchial wall thickening. In addition, CT imaging can be helpful to further identify specific radiographic abnormalities consistent with ABPA. bronchiectasis bronchial wall thickening (Choice B) It is important to verify appropriate inhaler technique in any patient with poorly controlled asthma; however, improper technique alone would not explain this patient's new onset of symptoms, radiographic findings, or peripheral eosinophilia. (Choice C) Bronchoscopy with bronchoalveolar lavage can be very useful in identifying the underlying cause of pneumonia in immunocompromised patients or in those whose clinical course is atypical. It can also be helpful in identifying lesions in patients who have frank hemoptysis (not blood-tinged sputum) or evidence of malignancy; however, it has no role in the evaluation of ABPA. (Choice D) Pulmonary function testing may reveal an obstructive pattern or a mixed obstructive and restrictive pattern in patients with ABPA; however, this study does not add significant diagnostic information to the evaluation of suspected ABPA. (Choice E) This patient lacks the significant risk factors (eg, immunosuppression, travel) and weight loss typically associated with pulmonary disease due to acid-fast bacteria (eg, tuberculosis, Mycobacterium avium complex infection, nocardiosis). Educational objective: Allergic bronchopulmonary aspergillosis should be suspected in patients with preexisting asthma or cystic fibrosis who develop recurrent episodes of fever, malaise, cough with brownish mucoid sputum, wheezing, or symptoms of bronchial obstruction. The initial evaluation should include either skin testing for Aspergillus or analysis of total and specific IgE concentrations. References: Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/27365388) Allergic bronchopulmonary aspergillosis: a perplexing clinical entity. (http://www.ncbi.nlm.nih.gov/pubmed/27126721) Pulmonary aspergillosis: a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/21881144)

A 38-Year-Old Woman Comes to the Office Due to Worsening