29M w severe persistent asthma p/w recurrent exacerbations despite optimal LABA/intranasal steroids. Abs eos 1250, total Ig E 1500, CT +mucus plugging, central bronchiectasis upper-middle lobes. Originally from Mexico, now in Texas. Which of the ff tests is indicated?
1/10
Great job! The majority got the right answer, allergic bronchopulmonary aspergillosis (ABPA).
Recurrent asthma exacerbations despite optimal asthma therapy & eosinophilia a/w mucus plugging and multilobar central bronchiectasis should raise suspicion for ABPA.
Great job! The majority got the right answer, allergic bronchopulmonary aspergillosis (ABPA).
Recurrent asthma exacerbations despite optimal asthma therapy & eosinophilia a/w mucus plugging and multilobar central bronchiectasis should raise suspicion for ABPA.
2/10
Aspergillosis, classified as saprophytic (aspergilloma), allergic (ABPA, hypersensitivity pneumonitis, allergic sinusitis), or invasive (pulmonary, other organs).
ABPA: hypersensitivity to A. fumigatus; can also occur from other fungi (referred as ABPM, M for mycosis).
Aspergillosis, classified as saprophytic (aspergilloma), allergic (ABPA, hypersensitivity pneumonitis, allergic sinusitis), or invasive (pulmonary, other organs).
ABPA: hypersensitivity to A. fumigatus; can also occur from other fungi (referred as ABPM, M for mycosis).
3/10
Pathogenesis is poorly understood. Involves induction of Th2 predominant response to A. fumigatus in genetically predisposed individuals. Eosinophilic response causes airway damage.
Pathogenesis is poorly understood. Involves induction of Th2 predominant response to A. fumigatus in genetically predisposed individuals. Eosinophilic response causes airway damage.
4/10
Frequent asthma exacerbation, most common Sx. May have fever/new infiltrates, can mimic many causes of pneumonia.
Dx rests on a high suspicion for ABPA; requires a predisposing factor, & lab/radiologic features👇 bit.ly/2RhCgZi
Frequent asthma exacerbation, most common Sx. May have fever/new infiltrates, can mimic many causes of pneumonia.
Dx rests on a high suspicion for ABPA; requires a predisposing factor, & lab/radiologic features👇 bit.ly/2RhCgZi
5/10
Fleeting CXR infiltrates👇 is characteristic; seen 40-77% of patients but not specific. bit.ly/33pDgjE
Transient ("migratory") infiltrates may be seen in Loeffler’s, lupus pneumonitis, cocaine smoking, COP, radiation pneumonitis, etc bit.ly/3htY4vf
Fleeting CXR infiltrates👇 is characteristic; seen 40-77% of patients but not specific. bit.ly/33pDgjE
Transient ("migratory") infiltrates may be seen in Loeffler’s, lupus pneumonitis, cocaine smoking, COP, radiation pneumonitis, etc bit.ly/3htY4vf
6/10
Bronchiectasis is also not specific (seen in asthma w/o ABPA). Findings of central bronchiectasis (affecting medial 1/2 - 2/3 of lung) in ≥3 lobes & high-attenuation mucoid (visually denser than paraspinal muscle) 👉 highly suggestive of ABPA. bit.ly/33pDgjE
Bronchiectasis is also not specific (seen in asthma w/o ABPA). Findings of central bronchiectasis (affecting medial 1/2 - 2/3 of lung) in ≥3 lobes & high-attenuation mucoid (visually denser than paraspinal muscle) 👉 highly suggestive of ABPA. bit.ly/33pDgjE
7/10
Total serum Ig E, most useful test not only for dx but also for follow-up. It is the “pro-BNP” of ABPA exacerbation👇 bit.ly/33pDgjE; doubling signifies exacerbation, while a drop by 35-50% with steroid signifies adequate response to Tx (never normalizes).
Total serum Ig E, most useful test not only for dx but also for follow-up. It is the “pro-BNP” of ABPA exacerbation👇 bit.ly/33pDgjE; doubling signifies exacerbation, while a drop by 35-50% with steroid signifies adequate response to Tx (never normalizes).
8/10
Take note that demonstration of A. fumigatus (sputum, bronchoscopy, biopsy) is not necessary and is not part of routine diagnostics.
There’s quite a list of DDX to keep in mind👇So, choices provided in the MCQ are all reasonable options.
@grepmeded @rabihmgeha @DxRxEdu
Take note that demonstration of A. fumigatus (sputum, bronchoscopy, biopsy) is not necessary and is not part of routine diagnostics.
There’s quite a list of DDX to keep in mind👇So, choices provided in the MCQ are all reasonable options.
@grepmeded @rabihmgeha @DxRxEdu
9/10
Oral steroid, mainstay of tx. No consensus on dose/duration (months to a year of tapering guided by Ig E). Experts recommend antifungals only after 1st relapse despite steroids bit.ly/2RhCgZi. IDSA recommends steroids+antifungals bit.ly/2RlyvSQ.
Oral steroid, mainstay of tx. No consensus on dose/duration (months to a year of tapering guided by Ig E). Experts recommend antifungals only after 1st relapse despite steroids bit.ly/2RhCgZi. IDSA recommends steroids+antifungals bit.ly/2RlyvSQ.
10/10
Time for #spacedlearning, on a related topic
Review treatment of invasive aspergillosis👇 from the outstanding tweetorial from ID Fellows Network @ID_fellows @swinndong @NNolanMD @LeMiguelChavez @JonathanRyderMD @DrH_flu @TxID_Edu
Time for #spacedlearning, on a related topic
Review treatment of invasive aspergillosis👇 from the outstanding tweetorial from ID Fellows Network @ID_fellows @swinndong @NNolanMD @LeMiguelChavez @JonathanRyderMD @DrH_flu @TxID_Edu
https://twitter.com/ID_fellows/status/1300819786574770181?s=20
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