A 34-year-old woman comes to the office for evaluation of recurrent transient pulmonary infiltrates. The patient has a history of bronchial asthma and has had several exacerbations over the past few years, particularly during the winter months. She is currently asymptomatic. She has no other medical problems and has never traveled outside the United States. Her medications include albuterol as needed and medium-dose inhaled glucocorticoids. Temperature is 37.1 C (98.8 F). Physical examination is unremarkable. Complete blood count shows eosinophilia. A chest CT scan reveals proximal bronchiectasis. This patient's condition is most likely related to colonization with which of the following?
Allergic bronchopulmonary aspergillosis (ABPA) | |
History |
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Chest imaging |
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Diagnosis |
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Aspergillus fumigatus is a low virulence fungus that generally does not cause significant infections except in immunocompromised or debilitated patients. It may, however, colonize the bronchial mucosa. Patients with asthma or cystic fibrosis in particular may develop an allergic hypersensitivity reaction to the fungus. The result is allergic bronchopulmonary aspergillosis (ABPA), which occurs in 5%-10% of corticosteroid-dependent asthmatics. Patients with ABPA have very high serum IgE levels, eosinophilia, and IgE plus IgG serum antibodies to Aspergillus. There is intense airway inflammation and mucus plugging with exacerbations and remissions. Repeated exacerbations may produce transient pulmonary infiltrates and proximal bronchiectasis.
(Choice A) Although viral respiratory infections can cause asthma exacerbations and adenovirus colonization of the lung may be associated with asthma chronicity, pure viral pneumonias do not progress to bronchiectasis.
(Choice C) Asthmatics do not have a predisposition to lung colonization with Legionella.
(Choice D) Pseudomonas aeruginosa is an opportunistic, aerobic gram-negative rod that is a frequent, and sometimes deadly, pulmonary pathogen in patients with cystic fibrosis or neutropenia.
(Choice E) Although asthma may be a risk factor for the development of pneumococcal lung colonization and pneumonia, pneumococcal disease generally results in resolution with preservation of lung lobular architecture. Potential complications of pneumococcal bronchopneumonia or lobar pneumonia include lung abscess, empyema, and lung fibrosis. Bronchiectasis is not a common outcome of pneumococcal pulmonary disease.
(Choice F) Strongyloidiasis is typically asymptomatic but can sometimes cause pulmonary symptoms (eg, cough, asthma-like bronchospasm, hemoptysis) or a transient pneumonia as the larvae migrate through the lungs on their way to the laryngopharynx. However, progression to bronchiectasis is not commonly reported.
Educational objective:
Allergic bronchopulmonary aspergillosis (ABPA) due to Aspergillus fumigatus may complicate asthma. ABPA can result in transient recurrent pulmonary infiltrates and eventual proximal bronchiectasis.