Thread by @CPSolvers

1/Friends, it's time to break out those schemas with another case tweetorial! Thanks to @dminter89 for putting this together, and to @UCSFMedicine's @jakejmayfield for the case! #FOAMed #medtwitter #medthread

2/A 26-year-old man presented with 2 weeks of progressive shortness of breath and cough.

How would you approach his dyspnea?
Check out this schema from @JohnsHopkinsDOM's @BBroderickMD clinicalproblemsolving.com/%20dx-schema-d…

3/He had a h/o asthma and reports that his asthma control has been worse in recent months despite escalation in his home therapy.
On exam, he is afebrile, HR 80, BP 127/78, RR 18, and O2 sat 95%. He has occasional wheezes and rhonchi w/o focal findings.

4/What conditions do you consider in adult patients with apparently worsening asthma control?

5/The answer is all of the above!
Check out this schema for an approach to refractory asthma

6/On labs, his BMP is within normal limits.
His CBC is notable for WBC 8,600 with an absolute eosinophil count of 4,500. Take a minute to think through your approach to eosinophilia, and then check out this schema:
clinicalproblemsolving.com/dx-schema-eosi…

7/CXR showed prominent airways with tram line shadows. Non-con CT chest revealed diffuse, central bronchiectasis and tree-in-bud opacities. (image reference below)

8/We now see radiographic lung findings and marked eosinophilia - how might these two schemas overlap? Check out this venn diagram

9/What is the most likely diagnosis?

10/The total IgE level was 1250 IU/mL and the Aspergillus IgE was positive. This was diagnostic of Allergic Bronchopulmonary Aspergillosis (ABPA)!

11/Aspergillus spp. are ubiquitous fungal pathogens that can cause a wide range of disease in humans. The exact clinical manifestation is dependent on the immune status of the host, ranging from severe angioinvasive disease to hypersensitivity reactions.

12/ABPA occurs in patients with asthma or cystic fibrosis and represents an immune-mediated hypersensitivity to airway colonization by Aspergillus spp.

13/Clinically, it manifests as poorly controlled asthma, increased sputum production, mucous plugging, and occasionally hemoptysis. It should be considered in pts with worsening asthma control despite medication adherence.

14/A diagnosis of ABPA in pts with either asthma or CF requires (1) Aspergillus specific IgE (or + skin test), (2) elevated total serum IgE > 1000 IU/mL, and..

15/...(3) > 2 of the following features: serum precipitins for aspergillus, elevated eosinophil count, and/or characteristic radiographic findings (bronchiectasis, mucous plugging, nodules, transient infiltrates).

16/Complications of ABPA include bronchiectasis, pulmonary fibrosis, and progression to chronic pulmonary aspergillosis. Check out these articles to learn more!