Reviewer: S. Randhawa, M.D., Fellow, LSU (Shreveport) Department of Allergy & Immunology
A 60-year-old male with a long history of Allergic Bronchopulmonary Aspergillosis (ABPA) is her for a a follow-up. He has been followed by our clinic for the last 7 years. He has been on omalizumab (Xolair) for 3 years. He had one interruption of therapy for approximately a year when he was off Xolair because of health insurance issues and then Xolair was resumed 8 months ago. Since then, his condition has been stable, but he continues to have symptoms of shortness of breath, wheezing, and episodic ABPA exacerbations.
He developed another ABPA exacerbation 5 days ago with worsening shortness of breath, wheezing, and cough productive of yellow sputum, which turned green recently. He reports no fever, abdominal pain, nausea, vomiting, diarrhea or constipation. His symptoms are worsening despite taking prednisone 40 mg po daily for the last 4 days.
Past medical history
Allergic Bronchopulmonary Aspergillosis (ABPA), allergic rhinitis.
His maintenance dose of prednisone is 15 mg po every other day. He is also on Advair 500/50 mcg one inhalation bid, Flonase, albuterol, and theophylline 300 mg po bid. Hhe reports symptomatic improvement when he was on itraconazole for 3 months approximately 3 years ago.
Physical examination is positive for mild tachypnea in the range of 16-20 breaths per minute. He also has evidence of bilateral expiratory wheezing and pale boggy turbinates on both sides. The rest of the physical examination is unremarkable.
What is the most likely diagnosis?
This is a patient with ABPA exacerbation with good effect with itraconazole in the past and current evidence of intercurrent respiratory infection.
What would you do?
We decided to start Augmentin 875 mg po bid for 10 days. He reports no significant effect with levofloxacin (Levaquin) taken in the past, and repeatedly good symptomatic effect with Augmentin, and therefore we decided to prescribe the same antibiotic.
We also started itraconazole at a dose of 200 mg po bid for 16 weeks and we will perform liver function testing today and on monthly intervals while he is on itraconazole. At this point, we decided to continue Xolair and to re-evaluate him in near future.
What did we learn from this case?
Antifungals, and intraconazole in particular can have a steroid-sparing effect in some patients with ABPA. A monitoring of the liver enzymes is necessary.
Allergic Bronchopulmonary Aspergillosis. Merck Manual.
Allergic Bronchopulmonary Aspergillosis. NEJM.