Uncontrolled asthma and recurring pulmonary opacities: just asthma?

Abstract

In asthma, when comorbidities and common causes of poor control have been considered and treated, the clinician may speculate, 'Is it all asthma?'. In patients with uncontrolled atopic asthma with recurring episodes of symptoms mimicking pneumonia, the suspicion of allergic bronchopulmonary aspergillosis (ABPA) should remain high. ABPA is caused by a complex immunological hypersensitivity reaction to colonisation with Aspergillus fumigatus in the bronchial tree, and is characterised by the presence of atopic asthma, blood eosinophilia, migrating pulmonary opacities and potential bronchiectasis. This case report describes a delay in diagnosing ABPA which was imitating pneumonia. The clinician should pay increased attention to ABPA and test for this in patients with uncontrolled asthma with an ongoing requirement for oral corticosteroids and/or antibiotics and with pulmonary opacities on chest imaging.

Figure 1

(A and B) Chest X-ray on admission in posteroanterior projection with a pulmonary opacity and subsegmental atelectasis in the apical part of the middle lobe (A) with remission 2 months later (B). Courtesy of Department of Radiology, Odense University Hospital.

Figure 2

(A and B) High-resolution CT showing bilateral central bronchiectasis and patonogmonic ‘toothpate shadows’ (T in picture A) and ‘finger-in-glove’ (F in picture B) opacities in middle lobe and lingual segments representing mucus impaction in inflamed and thickened bronchi. Courtesy of Department of Radiology, Odense University Hospital.

Figure 3

Course of total IgE and Aspergillus fumigatus-specific IgE after initiation of treatment with prednisolone and itraconazole.