A 28-year-old man presented with chest pain, hemoptysis, and wheezing. He had a history of intermittent shortness of breath that occurred at least 3 times a year in the past 3 years; fever; and loss of appetite associated with headache, vomiting, and weakness. His medical history also included asthma, chronic gastritis, and more than 5 episodes of pneumonia since 1996. A test for hepatitis C virus (HCV) had yielded positive results.
On physical examination, the patient was in acute distress because of shortness of breath. He was febrile, with a temperature of 38.5°C (101.3°F); pulse rate, 120 beats per minute; blood pressure, 180/110 mm Hg; and respiration rate, 30 breaths per minute. Decreased breath sounds in the right lower lobe were noted on auscultation, and a dull sound was heard on percussion.
The initial workup included a complete blood cell count, basic metabolic panel, hepatitis panel, HIV testing, antineutrophil cytoplasmic antibody testing, and measurement of serum IgG and IgE antibody levels. The white blood cell count was 14,000/µL; erythrocyte sedimentation rate, 57 mm/h; serum IgE level, 17,259/µL; and HCV antibody titer, positive. Cultures of blood, urine, and bronchoalveolar lavage (BAL) fluid for fungi and bacteria were unremarkable, except for a few Gram-positive cocci on BAL fluid culture. The results of a tuberculin purified protein derivative (PPD) test were negative.
A chest radiograph showed an irregular opacity in the right lower lobe (Figure 1), consistent with pneumonia, and circular opacities in both lungs, which were confirmed by a CT scan of the chest (Figure 2). A transbronchial biopsy specimen from the right lower lobe demonstrated eosinophilia and hemosiderin-laden macrophages (Figure 3).
ABPA was first described by Hinson and associates1 in the United Kingdom in 1952.It is an allergic reaction to the fungus Aspergillus, characterized by inflammation of the bronchi or alveoli. Patients with ABPA commonly present with worsening symptoms of asthma, wheezing, cough that may produce brownish plugs or bloody sputum, shortness of breath, and fever.2,3
The prevalence of ABPA is relatively high in patients with asthma and cystic fibrosis.3,4 Data from the Epidemiologic Registry of Cystic Fibrosis (ERCF) indicate that the overall prevalence of ABPA in the ERCF population was 7.8% (range, 2.1% in Sweden to 13.6% in Belgium). The prevalence was low in persons younger than 6 years, but was almost constant--about 10%--thereafter. No differences based on sex were observed. ABPA affected 8% of the patients who had a DF508/DF508 genotype and 5% to 6% of those with DF508/G551D, DF508/G542X, and DF508/N1303K genotypes.4
1. Hinson KF, Moon AJ, Plummer NS.
Broncho-pulmonary aspergillosis; a
review and a report of eight new
cases. Thorax. 1952;7:317-333.
2. Irwin RS, Rippe JM, eds. Manual of
Intensive Care Medicine. 3rd ed. Philadelphia:
Lippincott Williams & Wilkins;
3. Moss RB. Allergic bronchopulmonary
aspergillosis. Clin Rev Allergy Immunol.
4. Mastella G, Rainisio M, Harms HK,
et al. Allergic bronchopulmonary aspergillosis
in cystic fibrosis. A European
epidemiological study. Epidemiologic
Registry of Cystic Fibrosis. Eur
Respir J. 2000;16:464-471.
5. Weinberger S. Principles of Pulmonary
Medicine. 3rd ed. Philadelphia:
WB Saunders Co; 1998:312-
6. Epler GR. Bronchiolitis obliterans
organizing pneumonia. Arch Intern
7. Neeld DA, Goodman LR, Gurney
JW, et al. Computerized tomography
in the evaluation of allergic bronchopulmonary
aspergillosis. Am Rev Respir
8. Angus RM, Davies ML, Cowan MD,
et al. Computed tomographic scanning
of the lung in patients with allergic
and in asthmatic patients with a positive
skin test to Aspergillus fumigatus.
9. Wark PA, Saltos N, Simpson J, et
al. Induced sputum eosinophils and
neutrophils and bronchiectasis severity
in allergic bronchopulmonary
aspergillosis. Eur Respir J. 2000;16: