Abstract Introduction Allergic bronchopulmonary aspergillosis (ABPA) is an immunologically mediated lung disease which primarily affects patients with asthma or cystic fibrosis. It results from repeated inhalation of Aspergillus spores, predominantly Aspergillus fumigatus, which elicits a Type I, Type III or Type IV hypersensitivity response, eventually leading to local inflammation which further causes increased mucus production, airway hyperreactivity, and bronchiectasis. Current diagnostic criteria require a diagnosis of asthma with total immunoglobulin (Ig)E levels of 1000 ng/ml, elevated serum IgE and/or IgG to Aspergillus, immediate cutaneous hyperreactivity, and central bronchiectasis. However, cases of ABPA without asthma have been reported, mainly in case reports. Due to its rarity, diagnosis is clinically challenging and can potentially lead to misdiagnosis and inappropriate treatment. Here we describe a patient without prior history of asthma who presented with chronic cough, ultimately diagnosed with ABPA. Case Report A 67-year-old female never smoker without significant past medical history or prior pulmonary disease, although with a history of atopy without asthma, presented with a chronic cough of 6 months. Her cough was incessant, productive of copious amounts of clear to yellowish phlegm. She denied fevers, night sweats, dyspnea, heartburn or postnasal drip. There was no reported history of environmental exposures or sick contacts. She was treated with four cycles of different antibiotics in the interim without any significant relief. Chest x-ray done for ongoing cough showed a 3.8 cm right perihilar mass. The subsequent CT chest showed prominent mucoid impaction and tree-in-bud opacification in anterior right upper lobe with lesser areas of similar findings in the right middle lobe and lingula. This led to pulmonary consultation, and subsequent blood work revealed WBC of 5.7 with absolute eosinophil count of 1120 and markedly elevated total IgE level of 4248. Aspergillus IgE was also elevated along with multiple other aeroallergens. ANCA testing was negative. Patient was treated with high-dose prednisone taper over 3 months with complete resolution of her symptoms. Repeat CT was dramatically improved with some residual bronchiectasis without mucoid impaction. Repeat IgE and absolute eosinophil count at end of treatment were 615 and 150 respectively. She has had sustained clinical remission over 18 months with most recent IgE 510. Conclusion ABPA without asthma is an elusive diagnosis because of existing criteria for diagnosis, typically requiring known asthma. Pulmonologists should maintain a high index of clinical suspicion for this condition, especially in patients presenting with peripheral eosinophilia and characteristic radiological features. This abstract is funded by: N/A
Qaiser et al. (Fri,) studied this question.