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Allergic bronchopulmonary aspergillosis or pulmonary tuberculosis: A case of mistaken identity?

Muthu V, Behera D, Agarwal R - Lung India (2015 Sep-Oct)

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India E-mail: agarwal.ritesh@outlook.in.

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Herein, we report the case of a 30-year-old female, who was erroneously diagnosed and treated for allergic bronchopulmonary aspergillosis (ABPA)... She was subsequently found to have pulmonary tuberculosis... The total IgE and eosinophil count were 235 IU/mL and 650 cells/μL, respectively... She was labeled as ABPA and oral methylprednisolone was started at a dose of 16 mg per day... No significant improvement was noted in her symptoms after two weeks, hence, the patient visited our chest clinic... A. fumigatus specific IgE was negative (0.03 kUA/L), eosinophil count was 220 cells/μL, and the total IgE level was 310 IU/mL... Acid-fast bacilli were detected in the BAL fluid, Xpert MTB/Rif was positive for Mycobacterium tuberculosis with no rifampin resistance... The patient was started on anti-tuberculosis therapy and significant improvement was noted after two weeks... Immediate cutaneous hypersensitivity to the A. fumigatus antigen has a sensitivity of about 90% in the diagnosis of ABPA, whereas, demonstration of specific IgE against A. fumigatus >0.35 kUA/L is 100% sensitive... Furthermore, the IgE levels were less than 500 IU/mL and this finding ruled out active ABPA as the cause of the patient's current symptoms... In recent times, evidence-based, cut-off values have been found to differentiate asthmatics with and without ABPA, with 100% specificity (combination of total IgE > 2347 IU/mL, A. fumigatus specific IgE > 1.91 kUA/L, and eosinophil count > 507 cells/μL)... Several features that pointed toward an alternate diagnosis in the index patient have thus been overlooked... Finally, in patients with non-resolving pulmonary opacities and negative sputum microbiology, it is imperative that a flexible bronchoscopy (with BAL and lung biopsy) be performed in the diagnostic workup.

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Related in: MedlinePlus

Chest radiograph showing homogenous opacity in the right lower zone
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Figure 1: Chest radiograph showing homogenous opacity in the right lower zone

Mentions: A 30-year-old female presented to her physician four months ago, with a two-week history of dry cough and minimal mucoid expectoration. There was no fever, anorexia, weight loss, hemoptysis, wheeze, chest pain or breathlessness. She denied a past history of any medical illness, tuberculosis or bronchial asthma. A chest radiograph revealed opacity in the right lower lobe [Figure 1]. The tuberculin skin test and sputum for acid-fast bacillus (AFB) were negative. The skin prick test for Aspergillus fumigatus and Aspergillus flavus were positive. The total IgE and eosinophil count were 235 IU/mL and 650 cells/μL, respectively. Computed tomography (CT) of the chest showed patchy consolidation and subsegmental atelectasis. She was labeled as ABPA and oral methylprednisolone was started at a dose of 16 mg per day. No significant improvement was noted in her symptoms after two weeks, hence, the patient visited our chest clinic. She was further investigated. A. fumigatus specific IgE was negative (0.03 kUA/L), eosinophil count was 220 cells/μL, and the total IgE level was 310 IU/mL. Glucocorticoids were tapered and stopped. Sputum for AFB was repeated twice, and was negative. Radiological worsening was observed in the CT chest, with areas of consolidation, centrilobular nodules, and tree-in-bud appearance in the right lower lobe [Figure 2]. Centrilobular nodules were also seen in left lower lobe. The patient underwent flexible bronchoscopy and bronchoalveolar lavage (BAL). Acid-fast bacilli were detected in the BAL fluid, Xpert MTB/Rif was positive for Mycobacterium tuberculosis with no rifampin resistance. The patient was started on anti-tuberculosis therapy and significant improvement was noted after two weeks.


Allergic bronchopulmonary aspergillosis or pulmonary tuberculosis: A case of mistaken identity?

Muthu V, Behera D, Agarwal R - Lung India (2015 Sep-Oct)

Chest radiograph showing homogenous opacity in the right lower zone
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4587019&req=5

Figure 1: Chest radiograph showing homogenous opacity in the right lower zone
Mentions: A 30-year-old female presented to her physician four months ago, with a two-week history of dry cough and minimal mucoid expectoration. There was no fever, anorexia, weight loss, hemoptysis, wheeze, chest pain or breathlessness. She denied a past history of any medical illness, tuberculosis or bronchial asthma. A chest radiograph revealed opacity in the right lower lobe [Figure 1]. The tuberculin skin test and sputum for acid-fast bacillus (AFB) were negative. The skin prick test for Aspergillus fumigatus and Aspergillus flavus were positive. The total IgE and eosinophil count were 235 IU/mL and 650 cells/μL, respectively. Computed tomography (CT) of the chest showed patchy consolidation and subsegmental atelectasis. She was labeled as ABPA and oral methylprednisolone was started at a dose of 16 mg per day. No significant improvement was noted in her symptoms after two weeks, hence, the patient visited our chest clinic. She was further investigated. A. fumigatus specific IgE was negative (0.03 kUA/L), eosinophil count was 220 cells/μL, and the total IgE level was 310 IU/mL. Glucocorticoids were tapered and stopped. Sputum for AFB was repeated twice, and was negative. Radiological worsening was observed in the CT chest, with areas of consolidation, centrilobular nodules, and tree-in-bud appearance in the right lower lobe [Figure 2]. Centrilobular nodules were also seen in left lower lobe. The patient underwent flexible bronchoscopy and bronchoalveolar lavage (BAL). Acid-fast bacilli were detected in the BAL fluid, Xpert MTB/Rif was positive for Mycobacterium tuberculosis with no rifampin resistance. The patient was started on anti-tuberculosis therapy and significant improvement was noted after two weeks.

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India E-mail: agarwal.ritesh@outlook.in.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Herein, we report the case of a 30-year-old female, who was erroneously diagnosed and treated for allergic bronchopulmonary aspergillosis (ABPA)... She was subsequently found to have pulmonary tuberculosis... The total IgE and eosinophil count were 235 IU/mL and 650 cells/μL, respectively... She was labeled as ABPA and oral methylprednisolone was started at a dose of 16 mg per day... No significant improvement was noted in her symptoms after two weeks, hence, the patient visited our chest clinic... A. fumigatus specific IgE was negative (0.03 kUA/L), eosinophil count was 220 cells/μL, and the total IgE level was 310 IU/mL... Acid-fast bacilli were detected in the BAL fluid, Xpert MTB/Rif was positive for Mycobacterium tuberculosis with no rifampin resistance... The patient was started on anti-tuberculosis therapy and significant improvement was noted after two weeks... Immediate cutaneous hypersensitivity to the A. fumigatus antigen has a sensitivity of about 90% in the diagnosis of ABPA, whereas, demonstration of specific IgE against A. fumigatus >0.35 kUA/L is 100% sensitive... Furthermore, the IgE levels were less than 500 IU/mL and this finding ruled out active ABPA as the cause of the patient's current symptoms... In recent times, evidence-based, cut-off values have been found to differentiate asthmatics with and without ABPA, with 100% specificity (combination of total IgE > 2347 IU/mL, A. fumigatus specific IgE > 1.91 kUA/L, and eosinophil count > 507 cells/μL)... Several features that pointed toward an alternate diagnosis in the index patient have thus been overlooked... Finally, in patients with non-resolving pulmonary opacities and negative sputum microbiology, it is imperative that a flexible bronchoscopy (with BAL and lung biopsy) be performed in the diagnostic workup.

No MeSH data available.


Related in: MedlinePlus