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The following article is a part of conference coverage from the American Academy of PAs 2021 Conference (AAPA 2021), held virtually from May 23 to May 26, 2021. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading PAs. Check back for more from AAPA 2021. |
Allergic bronchopulmonary aspergillosis (ABPA) is a form of invasive aspergillosis that predominantly affects people with asthma and cystic fibrosis. A case of ABPA in a woman with recently diagnosed asthma was presented by Julia Watters, PA-S, and colleagues at the American Academy of PAs 2021 Conference (AAPA 2021).1
A 56-year-old woman with recently diagnosed asthma presents to the emergency department with worsening shortness of breath starting 1 week earlier and room air oxygen saturation of 84%. The patient appears ill and in moderate respiratory distress, including accessory muscle use, tripoding, and tachypnea; decreased lung sounds globally; and inspiratory wheezing and audible rhonchi. A cardiac examination shows tachycardia. The patient is anxious but alert and oriented x3.
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The patient’s vital signs are as follows:
- Temperature, 98.6°F
- Heart rate, 90 beats per minute
- Respiratory rate, 35 breaths per minute
- Blood pressure, 151/71 mm Hg
- Oxygen saturation, 98% on 8 L/min supplemental oxygen via nebulizer
Patient history includes migraines, mitral valve prolapse, appendectomy, and tonsillectomy. The patient has no allergies and takes no medications. She has no history of smoking, alcohol, or drug use. Initial diagnostic testing (ie, complete blood cell count, chest radiograph, electrocardiogram, COVID-19 test, and urine and blood culture) is unremarkable.
The patient is admitted to the hospital for presumed asthma exacerbation.
Inpatient Diagnostic Testing
On the first day of her 9-day hospital stay, the patient begins treatment with albuterol plus ipratropium and corticosteroids with demonstrated improvement in peak flow. Supplemental oxygen delivery alternates between a Venturini oxygen mask and nasal cannula.
On day 2, she continues to demonstrate cough and chest tightness with frequent desaturations. A physical examination shows poor air movement bilaterally in the lower lobes and inspiratory wheezing in the right upper lobe.
On day 3, the chest radiograph is repeated and demonstrates bilateral lower lobe pneumonia. Sputum culture shows no growth. A 7-day antibiotic course for community-acquired pneumonia is initiated.
On day 4, albuterol plus ipratropium therapy is reduced from 3 times daily to twice daily per patient request. Oxygen saturation is between 92% and 96% on 6 L/min supplemental oxygen via nasal cannula. Computed tomography antiography (CTA) is ordered to rule out pulmonary embolism and demonstrates occlusion of the right middle, right lower, and left lower lobe bronchi indicative of mucoid impaction and/or aspiration. It also shows postobstructive atelectasis, postobstructive pneumonitis, and postobstructive pneumonia in the right middle, right lower, and left lower lobes, respectively.
On day 5, the patient experiences persistent hypoxia with a nonproductive cough and significantly worsened shortness of breath. The treatment team adds guaifenesin, chest physical therapy, airway vibration/clearance device, and acetylcysteine via inhalation to the patient’s treatment regimen.
By day 6, the patient is improving and supplemental oxygen is decreased to 4 L/min via nasal cannula with an oxygen saturation of 97%. Corticosteroid treatment is further reduced to once daily and acetylcysteine via inhalation is added.
On day 7, supplemental oxygen is further reduced to 2 L/min with a 90% saturation on room air and an improvement in peak flow to 250 L/min. The patient’s lower respiratory culture is positive for mold.
On day 8, supplemental oxygen is removed (95% oxygen saturation on room air). Sputum culture speciation shows Aspergillus fumigatus and the patient is diagnosed with ABPA. The patient is discharged on day 9 with pulmonary follow-up scheduled in the outpatient setting.
Case Discussion
Aspergillus is an environmentally ubiquitous fungi, and aspergillosis is associated with significant morbidity and mortality in patients who are immunocompromised or have underlying pulmonary conditions, according to the study authors, who are from Quinnipiac University Physician Assistant Program and Yale University Physician Associate Program. ABPA is an immunoglobulin E (IgE)-mediated hypersensitivity reaction that is of particular concern in people with asthma and/or cystic fibrosis. ABPA affects approximately 4.8 million patients globally; however, due to extreme variance in presentation, many patients remain undiagnosed.2 Additionally, no universally accepted ABPA diagnostic criteria exist.3,4
The primary treatment goals of ABPA include controlling symptoms of asthma or cystic fibrosis, preventing and/or treating pulmonary exacerbation, decreasing pulmonary inflammation, and reducing the progression of pulmonary disease.
The recommended initial treatment for ABPA is corticosteroid therapy and the treatment course can be individualized. Itraconazole and voriconazole can be used to reduce fungal load, which should in turn reduce the inflammatory reaction.3,4 Monoclonal antibody use, despite demonstrating positive outcomes in the literature, remains controversial in patients with ABPA.5
Recommended treatment monitoring should be conducted bimonthly using serum IgE concentrations.4 When ABPA is left untreated, patients may develop bronchiectasis, severe persistent asthma, pulmonary fibrosis, and eventual loss of pulmonary function.6-8
“Since her initial hospital admission, the patient has been followed by pulmonology and had 1 subsequent admission during the winter months,” said coauthor Johanna D’Addario, PA. “Repeat lower respiratory cultures have been negative.”
Research is currently underway to evaluate potential diagnostic biomarkers that can be used to aid in early diagnosis and streamline treatment, the study authors noted.
“Due to scarcity in publication and notoriety, ABPA is rarely included among a clinician’s differential when treating acute asthma or cystic fibrosis exacerbation,” the researchers wrote. “Delay in diagnosis has been linked to a number of lasting pulmonary sequelae in patients with ABPA.”
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References
1. Watters J, Yanker A, D’Addario J. Allergic bronchopulmonary aspergillosis in a 56-year-old female with recently diagnosed asthma. Poster presented at: American Academy of PAs 2021 Conference; May 23-26, 2021. Poster 231.
2. Denning DW, Pleuvry A, Cole DC. Global burden of allergic bronchopulmonary aspergillosis with asthma and its complication chronic pulmonary aspergillosis in adults. Med Mycol. 2013;51(4):361-370. doi:10.3109/13693786.2012.738312
3. Greenberger PA, Bush RK, Demain JG, Luong A, Slavin RG, Knutsen AP. Allergic bronchopulmonary aspergillosis. J Allergy Clin Immunol Pract. 2014;2(6):703-708. doi:10.1016/j.jaip.2014.08.007
4. Agarwal R, Sehgal IS, Dhooria S, Aggarwal AN. Developments in the diagnosis and treatment of allergic bronchopulmonary aspergillosis. Expert Rev Respir Med. 2016;10(12):1317-1334. doi:10.1080/17476348.2016.1249853
5. Eraso IC, Sangiovanni S, Morales EI, Fernández-Trujillo L. Use of monoclonal antibodies for allergic bronchopulmonary aspergillosis in patients with asthma and cystic fibrosis: literature review. Ther Adv Respir Dis. 2020;14:1753466620961648. doi:10.1177/1753466620961648
6. Kumar R, Gaur SN. Prevalence of allergic bronchopulmonary aspergillosis in patients with bronchial asthma. Asian Pac J Allergy Immunol. 2000;18(4):181-185.
7. Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Treating allergic bronchopulmonary aspergillosis: a review. Cureus. 2019;11(4):e4538. doi:10.7759/cureus.4538
8. Reddy A, Greenberger PA. Allergic bronchopulmonary aspergillosis. J Allergy Clin Immunol Pract. 2017;5(3):866-867. doi: 10.1016/j.jaip.2016.08.019.
