Allergy and Airway: Student/Resident Case Report Poster - Allergy and Airway |

Fatal Allergic Bronchopulmonary Aspergillosis Following Successful Treatment of Cavitary Pulmonary Mycobacterium Avium Infection FREE TO VIEW

Jeff Chambers, DO; Paul Moots, MD; John Farrell, MD
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Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):18A. doi:10.1016/j.chest.2016.08.021
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SESSION TITLE: Student/Resident Case Report Poster - Allergy and Airway

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Allergic bronchopulmonary aspergillosis (ABPA) and pulmonary mycobacterium avium complex (MAC) infection, while not mutually exclusive, have not previously been described as synergistic pulmonary processes resulting in mortality. ABPA can cause significant, irreversible lung destruction, but is mostly seen in conjunction with asthma or cystic fibrosis (CF). We present a fatal case of ABPA in a patient with chronic severe bullous emphysema, but no history of ABPA or pulmonary Aspergillosis who developed ABPA after completing a 1 year treatment for pulmonary MAC.

CASE PRESENTATION: A 60 year-old male with 10+ years of bullous emphysema, interstitial fibrosis, and organizing pneumonia presented with acute shortness of breath. In the past month he completed a 1 year treatment for MAC infection with negative AFB stain and culture on follow up. Chest x-ray revealed chronic cavitary lung disease with a new air-fluid level in a cavity in the right upper lobe. Antibiotics were started empirically for treatment of super-infected bullous lesion with associated pneumonia. Workup included positive antibody testing for A. fumigatus with 2 precipitins on immunodiffusion, peripheral eosinophilia (Abs eos = 5,650 cells/mm3), and serum IgE of 8334 kU/L. Aspergillus IgE level was also high: 20.4 kU/L. Cultures of sputum and bronchoalveolar lavage (BAL) fluid from bronchoscopy grew mixed respiratory flora and heavy A. fumigatus. During bronchoscopy there was significant hypoxia which resulted in termination of the procedure and transfer to the ICU, where therapy for suspected re-activation of MAC was started. Solumedrol and voriconazole were later started for suspected ABPA. Unfortunately, he continued to decline and died 9 days after admission.

DISCUSSION: ABPA is found almost exclusively with asthma or CF. The pathogenesis involves a hypersensitivity reaction following respiratory tract colonization by A. fumigatus. Diagnostic criteria include a combination of radiologic findings, symptoms, and serologic testing as well as a history of asthma or CF (1,2). Our patient met many of these criteria: cavitary lung lesions, central bronchiectasis, eosinophilia, elevated IgE, precipitating antibodies to Aspergillus, and growth of Aspergillus from multiple respiratory specimens (sputum and BAL), but did not have asthma or CF. At baseline he had a normal eosinophil count and onset of his acute illness started shortly after finishing successful treatment for pulmonary MAC infection.

CONCLUSIONS: Although ABPA has not previously been described in the setting of prior mycobacterial infection, pulmonary MAC is often very destructive, leaving pulmonary cavities that could make a patient susceptible for subsequent attack of ABPA.

Reference #1: Patterson K, Strek ME. Allergic bronchopulmonary aspergillosis. Proc Am Thorac Soc. 2010 May;7(3):237-44.

Reference #2: Agarwal R. Allergic bronchopulmonary aspergillosis. Chest. 2009 Mar;135(3):805-826.

DISCLOSURE: The following authors have nothing to disclose: Jeff Chambers, Paul Moots, John Farrell

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