A 26-year-old man with a 5-year history of asthma comes to the office for follow-up after a recent hospital discharge. The patient was admitted due to fever, shortness of breath, trace hemoptysis, and productive cough with brownish mucus; he was treated with oral glucocorticoids, antibiotics, and nebulized bronchodilators. There were 2 similar episodes in the past year which were treated in the emergency department with tapering oral glucocorticoids on each occasion. He has a history of "walking pneumonia." Current medications include fluticasone/salmeterol, montelukast, and as-needed albuterol. He does not smoke cigarettes. His father was a heavy drinker and died from liver cirrhosis. The patient is not in acute distress. Physical examination shows diffuse wheezing with adequate air entry. A high resolution CT scan shows central bronchiectasis and a right lower lobe infiltrate. Review of prior chest x-rays shows a lingular infiltrate and a left lower lobe infiltrate. Which of the following is the most likely cause of this patient's symptoms?

Question

A 26-year-old man with a 5-year history of asthma comes to the office for follow-up after a recent hospital discharge.  The patient was admitted due to fever, shortness of breath, trace hemoptysis, and productive cough with brownish mucus; he was treated with oral glucocorticoids, antibiotics, and nebulized bronchodilators.  There were 2 similar episodes in the past year which were treated in the emergency department with tapering oral glucocorticoids on each occasion.  He has a history of "walking pneumonia."  Current medications include fluticasone/salmeterol, montelukast, and as-needed albuterol.  He does not smoke cigarettes.  His father was a heavy drinker and died from liver cirrhosis.  The patient is not in acute distress.  Physical examination shows diffuse wheezing with adequate air entry.  A high resolution CT scan shows central bronchiectasis and a right lower lobe infiltrate.  Review of prior chest x-rays shows a lingular infiltrate and a left lower lobe infiltrate.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1b9_9c7c_8f63_db651835f218_MD0005_00 Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disorder that occurs in patients with asthma or cystic fibrosis. It is associated with noninvasive colonization of the airways by Aspergillus species. The pathophysiology of ABPA is related to an exaggerated IgE and IgG-mediated immune response to the Aspergillus fungus in the context of preexisting asthma. Typical clinical features include recurrent asthma exacerbations, fever, lethargy, cough with production of brown mucus plugs (which may contain eosinophils and grow Aspergillus), occasional hemoptysis, and fleeting infiltrates on lung imaging (eg, transient infiltrates in different parts of the lungs). Other diagnostic criteria include immediate reaction to Aspergillus antigen skin testing, elevated total (eg, >417 IU/mL) and Aspergillus-specific IgE, serum precipitins to Aspergillus antigen, central bronchiectasis on high-resolution CT, and peripheral eosinophilia. Once the diagnosis of ABPA is confirmed, glucocorticoids and itraconazole are used to control inflammation and prevent irreversible damage. (Choice A) Eosinophilic granulomatosis with polyangiitis (Churg-Strauss disease) is an uncommon auto-immune vasculitis. It is often associated with difficult-to-control asthma. Other clinical features include allergic rhinitis with nasal polyps, chronic sinusitis, mononeuropathy multiplex, and skin manifestations (eg, granulomas, palpable purpura). (Choice B) ABPA can be seen in cystic fibrosis (CF), which is related to a defect in chloride conduction. However, this patient lacks the severe recurrent infections starting at a young age that typify CF. (Choice D) An immunodeficiency syndrome (eg, common variable immunodeficiency) can cause recurrent infections but has no correlation with asthma and would not improve with corticosteroid treatment. (Choice E) Alpha-1 antitrypsin deficiency allows neutrophilic elastase to break down lung tissue and is a potential cause of emphysema. A history of hemoptysis, brownish cough, and fleeting infiltrates make ABPA more likely. Educational objective: Allergic bronchopulmonary aspergillosis (ABPA) is caused by a vigorous IgE and IgG immune-mediated hypersensitivity response to Aspergillus. It is usually seen in patients with preexisting asthma or cystic fibrosis. ABPA is characterized by fleeting infiltrates, recurrent asthma exacerbations, and central bronchiectasis. References: Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria. (http://www.ncbi.nlm.nih.gov/pubmed/23889240)

A 26-Year-Old Man with a 5-Year History of Asthma Comes