Case Report: Allergic Bronchopulmonary Aspergillosis Revealing Asthma.

Houda Snen,Bechir Louzir,Sana Jemel,Sonia Marouen,Nozha Ben Salah,Aicha Kallel,Hana Blibech,Slah Belhaj,Kalthoum Kallel,Nadia Mehiri

doi:10.3389/fimmu.2021.695954

Abstract

Allergic bronchopulmonary aspergillosis (ABPA) is an immunological pulmonary disorder caused by hypersensitivity to Aspergillus which colonizes the airways of patients with asthma and cystic fibrosis. Its diagnosis could be difficult in some cases due to atypical presentations especially when there is no medical history of asthma. Treatment of ABPA is frequently associated to side effects but cumulated drug toxicity due to different molecules is rarely reported. An accurate choice among the different available molecules and effective on ABPA is crucial. We report a case of ABPA in a woman without a known history of asthma. She presented an acute bronchitis with wheezing dyspnea leading to an acute respiratory failure. She was hospitalized in the intensive care unit. The bronchoscopy revealed a complete obstruction of the left primary bronchus by a sticky greenish material. The culture of this material isolated Aspergillus fumigatus and that of bronchial aspiration fluid isolated Pseudomonas aeruginosa. The diagnosis of ABPA was based on elevated eosinophil count, the presence of specific IgE and IgG against Aspergillus fumigatus and left segmental collapse on chest computed tomography. The patient received an inhaled treatment for her asthma and a high dose of oral corticosteroids for ABPA. Her symptoms improved but during the decrease of corticosteroids, the patient presented a relapse. She received itraconazole in addition to corticosteroids. Four months later, she presented a drug-induced hepatitis due to itraconazole which was immediately stopped. During the monitoring of her asthma which was partially controlled, the patient presented an aseptic osteonecrosis of both femoral heads that required surgery. Nine months after itraconazole discontinuation, she presented a second relapse of her ABPA. She received voriconazole for nine months associated with a low dose of systemic corticosteroid therapy with an improvement of her symptoms. After discontinuation of antifungal treatment, there was no relapse for one year follow-up.

Highlights

Fungal pulmonary infections are rare in immunocompetent patients
We report a case of allergic bronchopulmonary aspergillosis (ABPA) in a patient with a medical history of an allergic rhinitis, with no respiratory symptoms and who developed drug toxicity to corticosteroids to itraconazole
If total IgE level are over 1000 IU/mL, two among three criteria are sufficient for establishing the diagnosis of ABPA: positive serum precipitins/Aspergillus fumigatus IgG, eosinophil count >500 cell/L, chest CT consistent with ABPA (mucus impaction, tree-in-bud pattern, centrilobular nodules, mosaic attenuation [31]; high attenuation mucus, pathognomonic for ABPA [9, 32]; segmental, lobar and total lung collapse due to mucus plugs [33,34,35]; central or peripheral bronchiectasis)

Summary

INTRODUCTION

Fungal pulmonary infections are rare in immunocompetent patients. These infections can be caused by several pathogens such as Aspergillus, Pneumocytis jirovecii and Cryptococcus. We report a case of ABPA in a patient with a medical history of an allergic rhinitis, with no respiratory symptoms and who developed drug toxicity to corticosteroids to itraconazole. A 72-year-old woman, non-smoker, consulted in December 2017, an office-based pulmonologist for acute bronchitis with wheezing dyspnea In her medical history she reported an allergic rhinitis diagnosed in childhood without respiratory symptoms. Flexible bronchoscopy revealed a complete obstruction of the left primary bronchus by a sticky greenish material that could be removed (Figure 3) Bacterial culture of this material isolated Pseudomonas aeruginosa and the patient received an antibiotherapy associating Levofloxacin and Cefpodoxime for two weeks, with partial improvement in respiratory symptoms. In May 2019, the patient presented acute bronchitis with mucus produced by coughs She had persistent respiratory symptoms which were resistant to antibiotherapy and short-term systemic corticosteroid therapy. After discontinuation of antifungal treatment, there was no relapse for one year follow-up

DISCUSSION

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DATA AVAILABILITY STATEMENT