Abstract Allergic bronchopulmonary aspergillosis (ABPA) is an immune-mediated, hypersensitivity reaction to Aspergillus fumigatus, usually associated with asthma or cystic fibrosis. Typical presentation includes cough with expectoration of thick mucus, wheezing, and dyspnea. Occasional segmental collapse has been reported, but persistent, complete unilateral atelectasis is a rare phenomenon. This is a case of an asthmatic female with Samter’s triad who developed refractory left lung atelectasis from extensive mucus impaction secondary to ABPA. A 79-year-old female with severe asthma with fixed airflow obstruction and Samter’s triad presented with dyspnea following hospitalization for a vertebral compression fracture, during which she was treated for presumed community-acquired pneumonia. She required 2-3 L of supplemental oxygen and had a persistent cough. Chest x-ray showed complete opacification of the left hemithorax with volume loss and obstruction of the left main bronchus. Patient underwent bronchoscopy, which revealed extensive mucous plugging with particulate material throughout the left tracheobronchial tree with marked inflammation and mucosal friability. Despite two additional therapeutic bronchoscopies with removal of copious mucoid material and aggressive airway clearance regimens, she remained hypoxic with persistent left-sided collapse. Laboratory studies showed a total IgE of 2,492 IU/mL and Aspergillus fumigatus-specific IgE of 0.40 kU/L. Cytology from bronchoalveolar lavage showed marked acute inflammation with focal Charcot-Leyden crystals. Peripheral eosinophilia up to 9.7% was also noted on prior labs. Based on clinical presentation, imaging, and laboratory findings, a diagnosis of ABPA was made. The patient was treated with systemic corticosteroids, inhaled triple therapy, nebulized hypertonic saline and acetylcysteine, and percussive airway clearance with flutter valve and mechanical cough-assist device. Imaging demonstrated only a partial re-expansion of the left upper lobe with persistent lower lobe collapse. Upon discharge, the patient remained on 2 L supplemental oxygen with mild improvement in sputum clearance. This case demonstrates persistent, complete unilateral atelectasis as a rare and uncommon complication of ABPA. While lobar or segmental collapse may be noted as a manifestation of ABPA, the sustained collapse of an entire lung despite aggressive bronchoscopic clearance and medical management is atypical. This case highlights how extensive mucus plugging can cause severe airway obstruction and persistent lung collapse. It additionally underscores the challenge of managing refractory atelectasis in patients with underlying airway disease, emphasizing the importance of early recognition and multidisciplinary management to optimize airway clearance and improve outcomes. This abstract is funded by: None
Bharwani et al. (Fri,) studied this question.