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Allergic Bronchopulmonary Aspergillosis and Mycobacterium avium-intracellulare Complex in a Patient With Bronchiectasis FREE TO VIEW

Abdulilah Arafeh, MD; Sreelatha Naik*, MD; Amee Patrawalla, MD
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University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ

Chest. 2012;142(4_MeetingAbstracts):160A. doi:10.1378/chest.1389925
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SESSION TYPE: Infectious Disease Case Report Posters I

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Allergic bronchopulmonary aspergillosis (ABPA) and Mycobacterium avium-intracellulare complex (MAI) infection can have similar clinical and radiologic presentations. We present a case where both of these conditions were found during the evaluation of bronchiectasis, and we discuss how this case was managed.

CASE PRESENTATION: A 55 year-old British woman was referred to pulmonary clinic for evaluation of an abnormal chest x-ray. She reported a several month history of a minimally productive cough without fevers, weight loss or night sweats. Her only medication was a short-acting beta-agonist inhaler as needed for lifelong asthma. On exam, the patient had a body mass index of 19 kg/m2. Chest x-ray and chest computed tomography revealed predominantly central bronchiectasis in the upper lobes. Pulmonary function testing showed moderate obstructive defect. Laboratory work revealed a white blood cell count of 4,300 per microliter with 29 percent eosinophils. Three sputum cultures revealed MAI. Serum total IgE level was 2481 IU/mL. Further serology showed significantly elevated IgE for Aspergillus Fumigatus and IgE for Aspergillus Niger. The patient was started on azithromycin, rifampin and ethambutol for MAI, and she is planned to be started on steroids two months later for her ABPA.

DISCUSSION: Our patient had findings consistent with both APBA and MAI infection, in the absence of prior immunosuppression, although it is not clear which process began first. It is known that patient with bronchiectasis and other chronic lung diseases are predisposed to infections with MAI. The incidence of ABPA in patient’s preexisting MAI is less clear. One retrospective study showed increased incidence of ABPA in patients with MAI disease, but this was not statistically significant (1). Although co-occurrence of these entities is discussed in the literature rarely, treatment of the patient with this dual presentation is even more infrequently discussed. Immunosuppression with steroids for treatment of ABPA, may exacerbate even a dormant MAI infection. Failure to recognize and treat both entities may be seen as treatment failure rather than a failure of diagnosis, which could lead to progression of disease and possibly to pulmonary fibrosis (2).

CONCLUSIONS: MAI and ABPA may occur simultaneously in a patient, particularly with chronic lung disease. Recognition of both entities is essential to implement appropriate treatment and prevent progression of disease.

1) Kunst H et al. Nontuberculous mycobacterial disease and Aspergillus-related lung disease in bronchiectasis. Eur Respir J 2006; 28; 352-357.

2) Mendelson EB. Roentgenographic and clinical staging of allergic bronchopulmonary aspergillosis. Chest 1985;87;334-339

DISCLOSURE: The following authors have nothing to disclose: Abdulilah Arafeh, Sreelatha Naik, Amee Patrawalla

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University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ




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