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Case Report | Volume 15 Issue 1 (Jan - Feb, 2025) | Pages 345 - 347
Allergic Bronchopulmonary Aspergillosis in a Patient with Poorly Controlled Asthma
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1
Consultant Internal Medicine, Department of Internal Medicine, Al Zahra Hospital, Dubai
2
Head of Department (HOD) and Specialist in Internal Medicine, Department of Internal Medicine, Al Zahra Hospital, Dubai
3
Head of Department and consultant pulmonologist, Department of pulmonology AlZahra hospital Dubai
4
Specialist radiologist, Department of radiology, AlZahra hospital, Dubai.
Under a Creative Commons license
Open Access
Received
Jan. 29, 2024
Revised
Dec. 8, 2024
Accepted
Dec. 30, 2024
Published
Jan. 28, 2025
Abstract

Allergic Bronchopulmonary Aspergillosis (ABPA) is a pulmonary condition which is immune mediated and is most commonly seen in people with asthma or cystic fibrosis. This condition occurs as a result of hypersensitivity to the fungus Aspergillus. This report highlights a case of a 31-year-old female with poorly controlled bronchial asthma presenting with haemoptysis, shortness of breath, and characteristic radiological findings suggestive of ABPA. Her elevated total IgE levels, along with bronchoscopic findings of a fungal ball, were critical for diagnosis and management

Keywords
INTRODUCTION

Allergic Bronchopulmonary Aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus species, commonly affecting individuals with asthma or cystic fibrosis (1). The main characteristic features of ABPA are frequent exacerbation of asthma, bilateral pulmonary infiltrates, bronchiectasis, and eosinophilia. The clinical presentation of the disease may vary but the most common symptoms are productive cough, wheezing and haemoptysis. The diagnosis of ABPA involves clinical, radiological, and serological findings.  importance of early diagnosis and treatment is essential as it can significantly alter the disease course of the disease and prevent its long-term complications. This report discusses a case of ABPA in a patient with a history of poorly controlled asthma. Long-term sequelae of this disease are mostly due to the delay in diagnosis and undertreatment which can result in worsening of the lung function secondary to pulmonary fibrosis, bronchiectasis with chronic mucus production (2). The incidence of ABPA is 1%-2% in asthmatic patients and 1%-7.8% in patients with cystic fibrosis (3).

CASE REPORT

A 31-year-old female with a known history of poorly controlled bronchial asthma presented to the clinic with complaints of a productive cough, which had been associated with bloody sputum, and progressive shortness of breath for the past week. The patient denied any history of fever, chest pain, or significant weight loss. She also had no notable family history of respiratory diseases or atopy, except for a mild history of hay fever.

 

On physical examination, the patient was alert and oriented, with no signs of cyanosis or clubbing. Respiratory examination revealed bilateral wheezing with a prolonged expiratory phase. Her vitals were stable, and no signs of respiratory distress were noted at the time of the visit. Initial laboratory investigations, including complete blood count (CBC), C-reactive protein (CRP), renal function tests, and liver function tests, were all within normal limits. Sputum cultures for acid-fast bacilli (AFB) were negative on three separate occasions. A chest X-ray revealed bilateral large nodular, fluffy shadows in both upper lobes, which prompted further imaging

 

Figure 1: Chest Xray showing fluffy nodular shadows and branching opacities in both upper lobes

 

A computed tomography (CT) scan of the chest demonstrated dilatation of segmental and subsegmental bronchi, particularly involving the anterior and posterior segments of the right upper lobe and the apical posterior segment of the left upper lobe. The dilated bronchi exhibited internal areas of iso to hyper attenuation, consistent with mucoid impaction. Additionally, tiny nodular shadows with a "tree-in-bud" appearance were noted on the peripheral aspects of the dilated bronchi, indicative of airway inflammation and fungal involvement.

Figure 2: CT chest showing dilatation of segmental and subsegmental bronchi with iso to hyper attenuated areas within them with no enhancement on post contrast study suggestive of mucous impaction

 

Serologic testing revealed a markedly elevated total IgE level of 6758 IU/mL (normal range: 0-100 IU/mL), which is highly suggestive of an allergic response. The allergen specific IGE levels to Aspergillus Fumigatus were positive at 3.10 (positive-more than 0.1). Bronchoscopy revealed a fungal ball in the posterior segment of the right upper lobe bronchus, further supporting the diagnosis of ABPA.

Figure 3: Bronchoscopy-showing fungal ball in the posterior segment of the upper lobe bronchus