Abstract Introduction Careful evaluation of abnormal chest radiographic findings is crucial for establishing an accurate diagnosis, especially with abnormal radiographic findings that do not align with an existing diagnosis. Here, we present a case of diffuse alveolar damage in an asthma patient who was also diagnosed with allergic bronchopulmonary aspergillosis (ABPA). Case Presentation A 33-year-old male with a past medical history of asthma and eczema presented with one week of worsening dyspnea and cough. His symptoms initially started six months prior when he was diagnosed with eosinophilic pneumonia and started on corticosteroids with improvement. After discontinuing steroids, he had four emergency department visits for recurrent respiratory symptoms. On evaluation, vital signs exhibited exertional hypoxia to 72%. His physical exam demonstrated increased work of breathing; however, lung auscultation was clear. Lab work revealed an absolute eosinophil count of 550 but was otherwise unremarkable. CT chest showed upper lobe predominant nodules as well as fibrotic changes and diffuse ground-glass opacities (GGOs). He underwent bronchoscopy with bronchoalveolar lavage showing a cell count of 93% macrophages inconsistent with eosinophilic pneumonia. Given his history of asthma, peripheral eosinophilia, and upper lobe nodules on imaging, there was suspicion for ABPA, and subsequent testing showed total IgE of 39,996 and aspergillus IgE of 3.29 consistent with this diagnosis. However, due to GGO abnormalities, cryobiopsy was performed with pathology demonstrating diffuse alveolar damage, interstitial pneumonitis, and early fibrosis. The patient responded well to prednisone treatment and was started on dupilumab on one month follow-up. Discussion ABPA is a type I hypersensitivity reaction associated with asthma and cystic fibrosis. Radiographic findings typically include upper-lobe predominant bronchiectasis and nodules. Our patient’s CT chest, however, demonstrated fibrosis and ground-glass changes in a diffuse pattern inconsistent with ABPA warranting additional investigation with cryobiopsy. He endorsed no occupational exposures or tobacco smoking. He did use marijuana occasionally and painted recreationally using acrylic spray paint without use of a mask or respirator. This raised concern for inhalation injury as an etiology of his resulting diffuse alveolar damage. He was educated to wear a protective mask during painting. Conclusion This case highlights the occurrence of diffuse alveolar damage in a patient simultaneously diagnosed with allergic bronchopulmonary aspergillosis (ABPA). Cryobiopsy was instrumental in this diagnosis. Our case demonstrates the need for complete investigation of abnormal radiographic findings that cannot be fully explained by a known diagnosis. This abstract is funded by: None
Patadia et al. (Fri,) studied this question.