abpa

1. Moderator : Dr S.S. Gupta(HOD & Associate Professor)
Dr Abhishek Agarwal (Assistant Professor)
Dept. of Pulmonary Medicine, ELMCH
Pulkit Agarwal
3RD Year Resident
Pulmonary Medicine
An Interesting Case of Bronchial
Asthma with Fleeting Opacities

2. CASE HISTORY
 SHAKEELA
 40/F
 NONSMOKER
 EXPOSED TO DOMESTIC SMOKE FOR 30 YRS
 HOUSEWIFE
 LIVED IN KACCHA HOUSE
 WITH HER HUSBAND & 2 CHILDREN

3. PRESENTING COMPLAINTS
 BREATHLESSNESS FOR 20 YRS
 PRODUCTIVE COUGH FOR 5 YRS
 FEVER ON & OFF FOR 5 YRS

4. PRESENTING COMPLAINTS
 BREATHLESSNESS FOR 20 YRS
 PRODUCTIVE COUGH FOR 5 YRS
 FEVER ON & OFF FOR 5 YRS
ASTHMA LIKE

5. EXAMINATION
 Clubbing Grade II
 B/l coarse crepts with Rhochi

6. CHEST XRAYS

7. CHEST XRAYS
12/03/10 25/03/10

8. INVESTIGATIONS

9. INVESTIGATIONS

10. X-RAY ON ADMISSION

11. X-RAY ON ADMISSION

12. SPUTUM EXAMINATION

13. D/ds
 Allergic Broncho Pulmonary Aspergillosis
 Cystic Bronchiectasis cause ? Infective

14. D/ds
 Allergic Broncho Pulmonary Aspergillosis
 Cystic Bronchiectasis cause ? Infective
HRCT THORAX

17. HRCT FINDING

18. The patient
was put &
started on
Corticosteroids

19. SPIROMETRY

20. SPIROMETRY

21. SPIROMETRY
OBSTRUCTION

22. SPIROMETRY
OBSTRUCTION
GOOD BDR

25. CHEST X-RAY --- After 3 Months

26. Definition
 ABPA is an allergic pulmonary disorder
caused by hypersensitivity to Aspergillus
fumigatus clinically manifesting as chronic
asthma, recurrent pulmonary infiltrates, and
bronchiectasis
 Occurs in asthma or cystic fibrosis2
 result of immune response to Aspergillus
colonization of airway and poor clearance of
mucus secretions
 subsequent bronchiectasis, pulmonary
fibrosis, and compromise of pulmonary
function
 first described by Hinson et al in 1952 in UK
1.CHEST 2009; 135:805–826.
2. Middleton’s Allergy, Principle&Practice 7th edition.

27. Clinical feature
 Symptom
 occasionally be asymptomatic
 low-grade fever, wheezing, bronchial
hyperreactivity,
 hemoptysis, or productive cough
 Expectoration of brownish black mucus plugs (31 to
69%)
 Physical examination
 wheeze
 Clubbing (16% )
 coarse crackles (15%)
 localized findings of consolidation and atelectasis
during exacerbation
CHEST 2009; 135:805–826.

28. Definition
 ABPA is an allergic pulmonary disorder
caused by hypersensitivity to Aspergillus
fumigatus clinically manifesting as chronic
asthma, recurrent pulmonary infiltrates, and
bronchiectasis
 Occurs in asthma or cystic fibrosis2
 result of immune response to Aspergillus
colonization of airway and poor clearance of
mucus secretions
 subsequent bronchiectasis, pulmonary
fibrosis, and compromise of pulmonary
function
 first described by Hinson et al in 1952 in UK
1.CHEST 2009; 135:805–826.
2. Middleton’s Allergy, Principle&Practice 7th edition.

29. Radiologic Investigations
 Chest radiographic findings
 Transient changes
 Patchy areas of
consolidation
 Radiologic infiltrates:
toothpaste and gloved finger
shadows due to mucoid
impaction in dilated bronchi
 Collapse: lobar or
segmental
 Permanent changes
 Parallel-line shadows
representing bronchial
widening
 Ring-shadows 1–2 cm in
diameter representing
dilated bronchi en face
 Pulmonary fibrosis: fibrotic
scarred upper lobes with
cavitation
 HRCT findings
 Central bronchiectasis
 Mucus plugging with
bronchoceles
 Consolidation
 Centrilobular nodules
with tree-in-bud
opacities
 Bronchial wall
thickening
 Areas of atelectasis
 Mosaic perfusion with
air trapping on
expiration
CHEST 2009; 135:805–826

30. Diagnosis and Diagnostic Criteria
 Rosenberg-Patterson criteria
 Major criteria ( ARTEPICS )
 A = Asthma
 R = Roentgenographic
fleeting pulmonary opacities
 T = Skin test positive for
Aspergillus (type I)
 E = Eosinophilia
 P = Precipitating Abs (IgG) in
serum
 I = IgE in serum elevated ( >
1,000 IU/mL)
 C = Central bronchiectasis
 S = Serums A fumigatus-
specific IgG and IgE (more
than twice the value of
pooled serum samples from
patients with asthma who
have Aspergillus
hypersensitivity)
 Minor criteria
 Presence of Aspergillus in
sputum
 Expectoration of brownish
black mucus plugs
 Delayed skin reaction to
Aspergillus Ag (type III )
 presence of 6 of 8 major
criteria makes diagnosis
almost certain; disease is
further classified as ABPA-
S or ABPA-CB
CHEST 2009; 135:805–826

31. Complication
 recurrent asthma exacerbations
 development of bronchiectasis
 subsequent pulmonary hypertension
 Respiratory failure
CHEST 2009; 135:805–826

32. Management
 Systemic Glucocorticoid Therapy
 treatment of choice for ABPA
 Suppress immune hyperfunction & antiinflammatory
 Long term therapy not recommended
 Regimen 2 (steroid dependence 13.5%)
 Prednisolone, 0.75 mg/kg/d, for 6 wk, 0.5 mg/kg for
6 wk, then tapered by 5 mg every 6 wk to continue
for total duration of at least 6 to 12 mo.
 total IgE levels are repeated every 6 to 8 wk for 1 yr
to determine baseline IgE
CHEST 2009; 135:805–826

33. Management
 Follow-up and monitoring
 Hx and PE , chest radiograph, and total IgE every 6
wk to demonstrate decline in IgE levels and clearing
of chest radiograph
 35% decline in IgE level signifies satisfactory
response to therapy
 Doubling of baseline IgE : silent ABPA exacerbation
 If cannot be tapered off prednisolone, disease has
evolved into stage IV. Management should be
attempted with alternate-day prednisone with least
possible dose
 Monitor for adverse effects (eg, HT, secondary DM)
 Prophylaxis for osteoporosis: oral calcium and
CHEST 2009; 135:805–826

34. Management
 Oral itraconazole
 Dose: 200 mg bid for 16 wk then once a day for 16
wk
 Indication: First relapse of ABPA or glucocorticoid-
dependent ABPA
 Follow-up and monitoring
 Monitor for adverse effects (eg, nausea, vomiting,
diarrhea,and elevated liver enzymes)
 Monitor for drug–drug interactions
 Monitor clinical response based on clinical
course,radiography, and total IgE levels
CHEST 2009; 135:805–826

35. Treatment with itraconazole
 reduces immune activation in ABPA
 improves short-term symptoms
 Reduces frequency of exacerbations that require
use of oral corticosteroids
 Not shown improvement in lung function
 may exacerbate adrenal suppression seen with
regular corticosteroid use
Respiratory Medicine (2004) 98, 915–923

36. THANK
YOU