A 33-year-old man with a history of asthma and chronic rhinosinusitis comes to the emergency department complaining of shortness of breath. He developed an upper respiratory infection 3 days earlier and woke today with increased sinus headache and mild dyspnea. He started diphenhydramine, albuterol, and ibuprofen. He also took his normal dose of fluticasone/salmeterol 250/50 and nasal fluticasone but became increasingly dyspneic over the next 3 hours. He has had sinus surgery twice (most recently last year) and removal of nasal polyps 2 years ago.
The patient is in mild respiratory distress. His pulse is 115/min, respirations are 23/min, and pulse oximetry is 98% on 2L oxygen by nasal canula. Examination reveals significant rhinorrhea, diffuse bilateral wheezes, conjunctival injection, and facial erythema. He is given methylprednisolone and albuterol nebulizer treatments, with improvement of his symptoms over the next 24 hours.
In addition to tapering doses of prednisone, which of the following would most likely benefit this patient?

Question

A 33-year-old man with a history of asthma and chronic rhinosinusitis comes to the emergency department complaining of shortness of breath.  He developed an upper respiratory infection 3 days earlier and woke today with increased sinus headache and mild dyspnea.  He started diphenhydramine, albuterol, and ibuprofen.  He also took his normal dose of fluticasone/salmeterol 250/50 and nasal fluticasone but became increasingly dyspneic over the next 3 hours.  He has had sinus surgery twice (most recently last year) and removal of nasal polyps 2 years ago.
The patient is in mild respiratory distress.  His pulse is 115/min, respirations are 23/min, and pulse oximetry is 98% on 2L oxygen by nasal canula.  Examination reveals significant rhinorrhea, diffuse bilateral wheezes, conjunctival injection, and facial erythema.  He is given methylprednisolone and albuterol nebulizer treatments, with improvement of his symptoms over the next 24 hours.
In addition to tapering doses of prednisone, which of the following would most likely benefit this patient?

Quizplus · Accepted Answer

11ec193a_969c_8433_853d_89090acbe060_MD0002_00 This patient's presentation is consistent with aspirin-exacerbated respiratory disease (AERD), as summarized in the table. AERD affects up to 20% of adult asthmatics and usually presents with the classic triad of chronic rhinosinusitis with polyposis, asthma, and aspirin (or NSAID) sensitivity. Patients usually develop refractory rhinitis in their 30s followed by chronic rhinosinusitis with anosmia and nasal polyposis. The rhinosinusitis progresses to lower-airway inflammation, resulting in asthma. Aspirin and NSAID sensitivity develops during this progression. NSAIDs can induce life-threatening asthma, nasal and/or ocular symptoms, and facial flushing or erythema. The reaction is not an IgE-mediated allergic response but is likely a shift in the arachidonic acid metabolic pathway causing excessive leukotriene production. Diagnosis is made clinically with history of aspirin or NSAID reaction. Treatment involves optimal asthma therapy, surgery for chronic rhinosinusitis, and avoidance of NSAIDs or aspirin. Current guidelines also recommend a leukotriene receptor antagonist (e.g., montelukast) to improve pulmonary and sinus symptoms. Aspirin desensitization is considered in patients refractory to therapy or who require aspirin/NSAIDs for other chronic conditions (e.g., CAD, chronic headaches). arachidonic acid metabolic pathway (Choice A) Long-acting beta-2 agonist (salmeterol) use without concurrent inhaled corticosteroids can be associated with increased asthma attacks due to down regulation of beta-2 receptors. However, this patient has more than simple asthma symptoms. (Choice B) AERD is not due to infectious causes but is an abnormal response to a drug. Therefore, a macrolide antibiotic would not help this patient. (Choice D) Anti-IgE therapy is beneficial in IgE-mediated conditions such as moderate to severe asthma with perennial allergies. However, AERD is not IgE mediated. (Choice E) Adding tiotropium can improve symptoms and lung function in uncontrolled asthmatics, but leukotriene antagonists are preferred in patients with AERD. Educational objective: Aspirin-exacerbated respiratory disease usually presents with the classic triad of nasal polyposis, asthma, and aspirin (or NSAID) sensitivity. The reaction is not an IgE-mediated allergic response but is likely a shift in the arachidonic acid metabolic pathway causing excessive leukotriene production. These patients should be treated with leukotriene antagonists and optimal asthma management. __________ References: Aspirin and asthma (http://www.ncbi.nlm.nih.gov/pubmed/11083703) Aspirin-sensitive asthma (http://www.ncbi.nlm.nih.gov/pubmed/15836503)

A 33-Year-Old Man with a History of Asthma and Chronic