Differential diagnoses of bronchial asthma are diverse. Not all patients with wheezing or coughing are having bronchial asthma. In this presentation, I discussed about different case scenarios to broaden our knowledge to think out of the black box.

1. Pseudoasthma
When Cough+Wheezing ≠ BA
TKT

2. CASE 1
Adam, 15-year-old teen, c/o chronic cough x 10/52,
a/w rhinorrhea and sneezing. He denied
fever/constitutional sx. His mother claims that the
symptom exaggerates especially during rainy
season. Two years ago, he had sinusitis. His sister
has BA.
What could be the possible diagnosis?
A. Chronis sinusitis
B. Pulmonary tuberculosis
C. Bronchial asthma
D. Allergic rhinitis
E. Eosinophilic granulomatosis with polyangiitis

3. ANSWER- D

4. Upper Airway Cough Syndrome
• Previously called “postnasal drip syndrome”
• Including allergic, non-allergic, acute
nasopharyngitis, and sinusitis

5. CASE 2
Mr C, 50-year-old, c/o cough x 3/12 a/w throat
itchiness. Sx worsens after taking heavy meals and
during sleep. Allergy hx: alcohol/eggs. + strong
FmHx of BA. He works as a plumber. Sputum
analysis: esinophil 0 cell. PMedHx: HTN on ACEi x 5
years.
What could be the diagnosis?
A. Occupational asthma
B. Cough variant asthma
C. GERD
D. Eosinophilic bronchitis
E. ACEi induced cough

6. ANSWER- C

7. CASE 3A middle-aged man, u/l
DM/HTN/IHD with h/o MI, p/w
SOB and cough x 1/12. He is a
active smoker/alcoholic. O/E
JVP ↑. + audible wheezing. +
tender liver 3FB. Lungs:
generalized rhonchi. BNP is
high. What is the diagnosis?
A. COPD/BA
B. ILD
C. CCF
D. Bronchopneumonia
E. Mediastinal mass with
airway obstruction

8. ANSWER- C

9. CASE 4
Adam, 15-year-old school boy,
c/o frequent epistaxis and
sinusitis within 3/12, a/w SOB
and wheezing. He was started
on turbuhaler Symbicort 2
puffs BD. His symptoms
worsened.
FBC: hypereosinophilia. One of
autoAb tests turned back +ve,
as shown in the picture.

10. What is the possible diagnosis in this case?
A. Hypereosinophilic granulomatosis with polyangiitis
B. Hypereosinophilic pneumonitis
C. Invasive aspergillosis
D. Parasitic infection
E. Lymphangitis carcinomatosis

11. ANSWER- A

12. ANCA- anti-nucleolar cytoplasmic Ab
(immunofluorescent stain)
C-ANCA (cytoplasmic) P-ANCA (perinuclear)

14. Churg-Strauss Syndrome
- Eosinophila
- Asthma
- Granulomas

15. CASE 5
Mr A c/o cough and wheezing, SOB x 2/12, a/w
LOA+LOW 10kg in 2/12. He also c/o chronic
diarrhoea and uncured skin rash. O/E, he was
cachexic. SPO2 ↓ RA 100%. Lungs: rhonchi +
audible wheezing. CVS: S1 soft with PSM over
LSE.

16. What is the possible diagnosis?
A. BA
B. Hypersensitivity pneumonitis
C. Psoriatic ILD
D.Pulmonary carcinoid
syndrome
E. Pulmonary sarcoidosis

17. ANSWER- D

18. Pulmonary Carcinoid Syndrome
• Neuroendocrine
tumor characterized
by neuroendocrine
differentiation and
indolent clinical
behaviour
• a/w secretion of
serotonin and other
neuropeptides into
systemic circulation

20. PELLARGA- lacked vit
B3 (Niacin)
Tryptophan- used up
for serotonin synthesis
and inadequate for
Niacin production

21. Diagnostic Workout
• Urine 5-HIAA ↑
• Serum chromogranin A
↑
• Gastrin-releasing
peptide ↑
• CT/PET-CT
• Bronchoscopy
• HPE

22. (A) Posterior-anterior (PA) chest radiograph demonstrating a nodular
opacity (arrow) in the right middle lobe with volume loss on the
right. The nodule is better visualized on the axial computed
tomography (CT) image of the chest.
(B) Just below the level of the carina (arrow). At surgical resection
the nodule proved to be a typical carcinoid.

23. HPE
Photomicrograph showing a carcinoid
tumor of the lung with a characteristic
neuroendocrine growth pattern
Normal alveolar tissues

24. CASE 6
Pn. Rosmah, 55-year-old housewife, a survivor
of multiple myeloma, p/w chronic cough x 3/12
a/w intermittent wheezing. Two months ago,
she was diagnosed late-onset BA and started on
MDI Salbutamol. O/E obesed, not tachypnoeic.
Lungs: occasional rhonchi.
Blood test: eosinophila. Serum IgE level >
1000IU/ml. IgE against A.fumigatus: detected.
Sputum TB PCR: negative. Sputum culture:
sterile. PBF: normal morphology.

25. What is the appropiate treatment?
A. Add in inhaler of LABA + high dose ICS
B. High dose of prednisolone
C. IV liposomal Amphotericin B
D. Chemotherapy

26. ANSWER- B

27. Allergic bronchopulmonary aspergillosis
(ABPA)
• It is a complex hypersensitivity reaction – in
respond to colonization of the airways with
Aspergillus fumigatus
Predisposing conditions (one must be present):
Asthma
Cystic fibrosis
Obligatory criteria (both must be present):
Aspergillus skin test positivity or elevated IgE levels against Aspergillus fumigatus
Elevated total IgE concentration (typically >1000 IU/mL, but if the patient meets all other
criteria, an IgE value <1000 IU/mL may be acceptable)
Other criteria (at least two must be present):
Precipitating serum antibodies to A. fumigatus or elevated serum Aspergillus IgG by
immunoassay
Radiographic pulmonary opacities consistent with ABPA
Total eosinophil count >500 cells/microL in glucocorticoid-naïve patients (may be historical)

30. Management of AEBA
• Initial approach-> prednisolone (mainstay of
Rx) 0.5mg/kg/day x 2/52 then taper down
within 3/12. (may require 1mg/kg/day in
severe case)=> AIM: reduction of total serum
IgE by 25% in 1st month then 60% in 2nd month
+ clinical improvement + resolution of
radioimaging findings
• Anti-fungal agents(itraconazole/voriconazole)
4/12 if poor response to steroids
• Monoclonal Ab (e.g Omalizumab) in refractory
case

31. CASE 7
Mdm Suria, 45-year-old
schizophrenic patient, c/o
SOB and chest discomfort
x 1/52. She denied fever.
Last week, she had self-
harm. O/E + audible
wheezing (intermittent).
Lungs: + intermittent
rhonchi. Throat: clear.
What is the possible
diagnosis?
A.Neuroleptic syndrome
B. Foreign body ingestion
C. CAP with bronchospasm
D. Lung CA with brain mets
E. Bronchiolitis obliterans

32. ANSWER- B

35. Take Home Message
1. Cough and wheezing ≠ BA
2. Diagnosis of ‘so-called’ uncontrolled
asthma warrants further revision.

36. THANK YOU