Wednesday, May 18, 2005

Recalcitrant cough and bronchiectasis - Follow up

This is in reference to the Original post
- 74 year old woman with recalcitrant cough and bronchiectasis.

The following exams were performed shortly after her first visit with us(6 months after onset of symptoms):

CBC: WBC10; Seg51%/Lymph15%/M7%/Eos22%/Baso1%
IgE: 353 (0-150), Aspergillus IgE undetectable(RAST), Aspergillus skin test neg.

HRCT results
There is mild to moderate predominantly central bronchiectasis involving all lobes. Mucous plugging is noted in the lateral segment of the middle lobe, inferior segment of the lingula and in the left lower lobe. Patchy peripheral atelectasis/scarring is noted in the lateral segment middle lobe and the superior segment of the right lower lobe.

Bronchoscopy
Lung biopsies: Eosinophil-rich bronchitis with abundant mucus containing eosinophils, possibly allergic bronchopulmonary aspergillosis related.
Cytologic examination: Negative for neoplasm. Abundant eosinophils admixed with alveolar macrophages.No pathogens present with routine stains.
Gram stain neg. Culture: <10,000>Subsequent treatment and clinical course:
Based upon the results - patient was treated with 40mg prednisone followed by a slow taper. She responded well with decreased cough, improved sleep.

Results (after about 3 months)
Decreased cough. No wheezing on exam.
Spirometry: Fev1 2.07 L, nl volumes and diffusion
IgE 103
CBC: Eos 2%
ANCA neg.

ENT evaluation at OSH - nl CT sinuses and nl ENT evaluation.
Attempts to completely wean off prednisone resulted in exacerbation of her symptoms (increase ESR and slight increase in peripheral Eos as well) requiring burst of prednisone with subsequent stabilization.

Most recent attempt to wean off b/c of concern of steroid myopathy resulted in increased respiratory symptoms (IgE 161). Repeat Cx - oral flora.

See Original post for review of labs previously performed (Quant IgG nl). No significant exposures.
Thoughts, suggestions?

3 comments - CLICK HERE to read & add your own!:

Mike L said...

How about trying her on itraconazole?

Jennings said...

I was going to mention the itraconazole. I just staffed a case of ABPA with dramatic response to this medication. In you case, we know it is not ABPA, but it sure sounds like APBM. The negative IgE to aspergillus means that aspergillus is not the "M", that's all.

In terms of steroid sparing (if the myopathy becomes an issue), I wonder if there would be a role for omalizumab??

Baleeiro said...

You have my vote for itraconazole as well. As Jennings pointed out, the syndrome may be due to other fungi. Incidentally, did u check stool for O&P?