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: Further laboratory evaluation of the patient shows a serum total IgE level of 1,000 ng/mL. High-resolution CT scan of the lungs confirms the presence of bilateral upper lobe infiltrates and central bronchiectasis. Which of the following is the best next step in management of this patient?

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:  Further laboratory evaluation of the patient shows a serum total IgE level of >1,000 ng/mL.  High-resolution CT scan of the lungs confirms the presence of bilateral upper lobe infiltrates and central bronchiectasis.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Treatment for allergic bronchopulmonary aspergillosis (ABPA) is directed at acutely stopping the underlying inflammation and decreasing fungal burden to reduce the risk of recurrence. Systemic glucocorticoids are the mainstay therapy and have been shown to improve symptoms during acute exacerbations. They also speed the resolution of lung opacities on radiographic imaging, normalize eosinophil levels, and significantly reduce total IgE, which is serially monitored to assess clinical response. Antifungal therapy with either itraconazole or voriconazole should also be considered as it has been shown to reduce the Aspergillus load and, therefore, the antigenic stimulus for ABPA. In addition, antifungal therapy has been demonstrated to decrease glucocorticoid requirements. Other therapeutic options include omalizumab, a monoclonal antibody against IgE, which may be helpful in patients with ABPA and poorly controlled asthma. (Choice A) Albendazole is appropriate treatment for infection due to many helminthic organisms (eg, Ascaris lumbricoides, Enterobius vermicularis), but it does not have any activity against Aspergillus. (Choices B and D) This patient has no evidence of active tuberculosis or pneumonia, and neither antituberculosis medications nor levofloxacin are indicated in the treatment of ABPA or its exacerbations. (Choice C) Although other azoles are appropriate, fluconazole has limited activity against Aspergillus and is not first-line therapy for any form of Aspergillus infection. Educational objective: Treatment for allergic bronchopulmonary aspergillosis is directed at acutely stopping the underlying inflammation and reducing Aspergillus burden. Systemic glucocorticoids are the mainstay therapy with consideration of antifungal therapy (itraconazole or voriconazole) to decrease fungal burden and antigenic stimulus. 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