A 23-year-old man was referred to our hospital because of chronic cough for 6 months and markedly elevated eosinophil count. Sixteen years ago, he had been diagnosed with asthma and had used salbutamol intermittently. He was a lifelong non-smoker.
On examination, the white blood-cell count was 7,610/µL with a 37.1% of eosinophil (2,410/µL). Screening test results for parasites were negative. Total IgE was 2,500 IU/mL and the serum level of
Aspergillus-specific IgE was elevated (>50 kU/L).
Aspergillus-specific IgG was also elevated (>200 mg/dL). Allergy skin prick test showed positive reactions to
A. fumigatus. Pulmonary function test showed obstructive patterns with positive bronchodilator response, i.e., 410 mL (20%) increase from 2.00 L to 2.41 L of forced expiratory volume in 1 second (FEV
1) of FEV
1 after inhalation of beta2-agonist, 0.72 of FEV
1/forced vital capacity ratio, decreased forced expiratory flow between 25% and 75% of functional vital capacity (FEF
25-75%, 1.70 L; 36% of predictive value), and positive mannitol bronchial provocation test. High resolution computed tomography (HRCT) showed 3.3×2.0-cm-sized, ill-defined consolidation and peripheral ground glass opacity in the left lower lobe lateral basal segment (
Figure 1A). Central or peripheral bronchiectasis was not demonstrated. The patient was referred for a video-assisted thoracoscopic biopsy of the consolidation in the left lower lobe. Histologic features were organizing pneumonia filled with eosinophil-dominant inflammatory exudates. His clinical and laboratory findings fulfilled the six major diagnostic criteria of ABPA proposed by Rosenberg-Patterson
5 (i.e., asthma, pulmonary infiltration, immediate cutaneous hyperreactivity to
Aspergillus, peripheral eosinophilia, elevated serum IgE over 1,000 IU/mL, serum
A. fumigatus-specific IgG and IgE). On the diagnosis of ABPA, he began to be treated with 400 mg/day itraconazole and 1 mg/kg/day oral methylprednisolone. After 3 months later, consolidation in left lower lobe was completely disappeared. Blood eosinophil count became normalized (0.7%, 90/µL) and serum IgE level was decreased (1,632 IU/mL). So, steroid was slowly tapered and eventually wean. Regular radiologic and serologic work-up was performed thereafter.
After 1 year after completion of treatment, HRCT demonstrated 2.0×1.8-cm-sized ill-defined consolidation containing peripheral ground glass opacity in left lower lobe superior segment (
Figure 1B). Laboratory test showed a peripheral eosinophilia (19.2%, 1,180/µL), high total IgE level (>3,000 IU/mL). After considering the radiology and serology, a recurrence of ABPA was diagnosed. After re-treated with itraconazole and oral methylprednisolone in 1 month, HRCT showed remarkable improvement. He was treated with oral methylprednisolone at a maintenance dose for 6 months and tapered.
After 8 month after second treatment, 2.1×1.5-cm-sized, ill-defined consolidation in the right upper lobe apical segment and small nodules and peripheral ground glass opacity in right upper lobe posterior segment was shown (
Figure 1C). Serologic evaluation showed eosinophilia (13.9%, 1,240/µL) and elevated total IgE (>3,000 IU/mL). As a result, third attack of ABPA was diagnosed. After retreatment with oral methylprednisolone and itraconazole, consolidation was disappeared.
After 3 months after completion of third treatment, consolidations were developed in right middle lobe and right lower lobe (
Figure 1D, E). Eosinophilia (25.1%, 1,850/µL) and elevated IgE (>3,000 IU/mL) was shown again. He was re-treated with oral methylprednisolone and itraconazole. After 3 months later, follow-up radiologic evaluation demonstrated complete remission. The bronchiectasis was not developed (
Figure 1F).