Case Report: Allergic bronchopulmonary aspergillosis in a 21-year-old female patient with no prior asthma

Presenting complaint

A 21-year-old female medical student presented with complains of breathlessness, which was MMRC grade II in beginning and gradually progressed to MMRC grade III, and history of seasonal variation for the last 15 years. She is known case of breathlessness evaluation since 2018 on rotacap. She also complained of cough with yellowish expectoration along with cold & chest pain over the last 5 days. The patient had a history of dust allergy with biomass exposure for 11 years with no any addictions.

Clinical examination

The patient’s vital signs, which included a value of 110/70 mmHg for blood pressure, 84 for pulse rate, 20 for respiratory rate, and 94% for peripheral oxygen saturation while breathing room air, were all within the normal range. During the chest examination, bilateral rhonchi were detected upon auscultation, indicating the presence of abnormal breath sounds suggestive of respiratory issues. Heart sounds were present and no murmurs were found during a cardiovascular (CVS) examination, indicating no severe cardiac abnormalities at the time. The patient was discovered to be conscious and oriented throughout the CNS (central nervous system) assessment, demonstrating that they were completely mindful of their surroundings and position. According to laboratory results, the patient had eosinophilia, or an elevated eosinophil count, in their peripheral blood. The patient’s present respiratory symptoms may be related to eosinophilia, which has been linked to several medical disorders, including allergic responses and several respiratory illnesses. The patient’s diagnosis and continuing medical care benefited greatly from these clinical observations and test findings.

Diagnostic workup

Chest X ray (Figure 1) was suggestive of Bilateral Lower Zone Bronchiectatic changes.

Figure 1. Chest X-ray.

Pulmonary function tests demonstrated obstructive pattern with reduced FEV1 (Forced expiratory Volume in 1 second) and FEV1/FVC (Forced vital capacity ratio).

HRCT scan (Figure 2) showed cystic bronchiectatic changes in the left upper lobe, right lower lobe with fibrobronchiectatic changes in bilateral upper lobes, right middle lobe, diffuse ground glass opacities giving mosaic pattern in the bilateral lung parenchyma.

Figure 2. HRCT scan chest.

The patient’s laboratory investigations reveal several abnormal findings. First, the serum IgE level is significantly elevated at 658.1 IU/mL, well above the normal range of 52-423 IU/mL. Elevated IgE levels are often associated with allergic conditions and can be indicative of an immune response, such as the one seen in allergic bronchopulmonary aspergillosis (ABPA). The white blood cell count is also elevated at 13,300 wbcs/microliter, exceeding the normal range of 4,500-11,000 wbcs/microliter. This elevation may suggest an ongoing inflammatory or infectious process. The platelet count is elevated at 481,000/ml of blood, which is above the normal range of 150,000-450,000/ml. This could be a response to an underlying condition or inflammation in the body. The hemoglobin (Hb) level is within a slightly lower normal range at 12.5 gm/dl, with the normal range being 13-17 gm/dl. This might indicate mild anemia. Serum creatinine is slightly below the normal range at 0.5 mg/dL, which could be an indicator of kidney function. It falls below the reference range of 0.59-1.04 mg/dL. Sodium levels are lower than normal at 130 mmol/L (normal range: 136-145 mmol/L), indicating hyponatremia, which could be related to other medical conditions or fluid imbalances. The erythrocyte sedimentation rate (ESR) is markedly elevated at 46 mm/hr, well above the normal range of 0-20 mm/hr. An elevated ESR is often associated with inflammation and can be indicative of an underlying inflammatory or infectious process. HbA1c, a measure of long-term blood sugar control, is elevated at 6.2%, which is above the normal range of 4%-5.6%. This suggests poorly controlled blood sugar levels, indicative of diabetes mellitus. Fasting glucose levels are significantly elevated at 216 mg/dL, well above the normal reference range of <100 mg/dL, further confirming the presence of poorly controlled diabetes. Urine sugars and urine albumin are both reported as “Nil,” indicating that there are no detectable sugars or albumin in the urine, which is reassuring in diabetes management. Tests for AFB smear & PCR and HHH (possibly for HIV) are reported as negative, suggesting no evidence of tuberculosis (AFB) or HIV infection. Acid-fast bacilli are a group of bacteria that have a unique cell wall structure, making them resistant to decolorization by acids during laboratory staining procedures.

In summary, these laboratory findings collectively suggest a complex clinical picture with potential underlying issues related to allergic bronchopulmonary aspergillosis (elevated IgE), inflammation (elevated ESR and white blood cell count), mild anemia (slightly low Hb), hyponatremia (low sodium), and poorly controlled diabetes (elevated HbA1c and fasting glucose). Further evaluation and consultation with a healthcare provider are essential to determine the underlying causes and develop an appropriate treatment plan.

Sputum culture identified Aspergillus fumigatus as the causative agent.

Treatment and management

The patient was admitted to the hospital’s respiratory department and received antifungal therapy, specifically oral itraconazole (200 mg) was given twice a day for 10 days in an effort to stop Aspergillus from spreading to the patient’s airways. An oral corticosteroid called prednisolone 0.5 mg/kg/days was given for 14 days on alternate days and, after discharge, 5 mg every two weeks for an additional three months to help treat the condition further. The patient was given these corticosteroids to lessen the inflammation of the eosinophils that was noticed. Nebulization therapy was used in conjunction with medication to treat the patient. The patient undertook nebulization with Budecort twice a day for 10 days and Duolin thrice a day for 10 days to focus relief and assist in managing respiratory problems.

Monitoring the patient’s progress and treatment reaction was one of the most crucial components of their care. In order to gauge the patient’s response to treatment, many follow-up appointments were set up. Lung function tests, IgE (immunoglobulin E) levels, and imaging examinations were repeated on a regular basis as part of this monitoring approach. These measurements aided medical personnel in assessing the efficacy of the therapy and making any necessary modifications to guarantee the patient’s well-being and recovery.

Outcome: The patient responded positively to the prescribed treatment regimen. Her symptoms improved significantly, and repeat HRCT scans showed improved changes. Long-term management remains essential to prevent relapses and minimize potential corticosteroid-related side effects.