Correspondence

Case 45-1993: Allergic Bronchopulmonary Aspergillosis

N Engl J Med 1994; 330:941March 31, 1994

Article

To the Editor:

In Case 45-1993 (Nov. 11 issue),1 a 23-year-old man with asthma is eventually given a diagnosis of allergic bronchopulmonary aspergillosis. I believe it was inappropriate to admit this patient to the hospital and to subject him to bronchoscopy or a mediastinoscopic examination.

The patient should have been seen for office or outpatient study. The physician could have seen the numerous eosinophils and Charcot-Leyden crystals in an unstained specimen of fresh sputum. These signs, with the characteristic history and radiographic findings, would have suggested allergic bronchopulmonary aspergillosis. Measurement of the serum IgE level, a blood count for eosinophils, a skin test for aspergillus, and a study of serum for aspergillus precipitins could have been ordered. Sputum could have been submitted for fungal culture. The patient should have returned in a few days for the reports. At that time the physician would have made a presumptive diagnosis of allergic bronchopulmonary aspergillosis and started outpatient treatment. A positive culture for aspergillus is not necessary to make this diagnosis.

If this patient's condition did not improve with steroid treatment, hospitalization and further study would have been appropriate.

John L. Guerrant, M.D.
University of Virginia School of Medicine, Charlottesville, VA 22908

1 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 45-1993). N Engl J Med 1993;329:1484-1491
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Joseph and Dr. Tierney of Massachusetts General Hospital reply:

To the Editor: It is difficult for us to comment on the initial treatment of this patient, who was referred directly to the thoracic surgery service for the evaluation of hilar adenopathy and mediastinal widening. Concern about the possibility of cancer or sarcoidosis led to the bronchoscopy and mediastinoscopic examination. At that time, perhaps because the patient's asthmatic symptoms were relatively minor, the diagnosis of allergic bronchopulmonary aspergillosis was apparently not considered.

We agree with Dr. Guerrant that the evaluation of this condition is generally based on the history, immunologic information including data on reactivity to aspergillus antigen, and sputum studies. Invasive procedures are rarely necessary. This case shows that the diagnosis does not necessarily require the presence of active or severe asthma, although this is often considered a key element. In fact, this diagnosis has been reported in the absence of clinical asthma.1 A heightened awareness of allergic bronchopulmonary aspergillosis and a high index of suspicion in patients with recurrent infiltrates, eosinophilia, and bronchiectasis, with or without active asthma, are necessary.

Patricia Maxwell Joseph, M.D.
Maureen Tierney, M.D.
Massachusetts General Hospital, Boston, MA 02114

1 References

1. 1

   Glancy JJ, Elder JL, McAleer R. Allergic bronchopulmonary fungal disease without clinical asthma. Thorax 1981;36:345-349
   CrossRef | Web of Science | Medline