A cough that doesn't fit the mould
Editor – We read with interest the lesson of month entitled A cough that doesn't fit the mould (Clin Med 2015;15:492–4). This is an interesting case report, which we believe highlights the difficulty in making a diagnosis and classifying Aspergillus-related pulmonary disease. Baggott et al have made a diagnosis of Aspergillus tracheobronchitis and mention that it is part of the spectrum of invasive Aspergillus disease. We believe it would be worth adding that both saprophytic (non-invasive) and invasive forms of Aspergillus tracheobronchitis exist.1,2 The latter requires the demonstration of fungal hyphae invading the bronchial mucosa, which was not demonstrated in this case. Where fungal hyphae are found in the bronchial tree without invasion this could be due to obstructing bronchial aspergillosis, which requires the absence of allergic disease,1 or mucoid impaction that is a non-specific sign of Aspergillus bronchial disease and is also a feature of allergic bronchopulmonary aspergillosis (ABPA). The case presented by Baggott et al had mucoid impaction resulting in obstruction and collapse of the right middle lobe. However, the patient developed features of an allergic reaction to Aspergillus evidenced by the positive grade-III specific Aspergillus IgE, high total IgE level (1,519 kU/L) and pulmonary eosinophilia (1.94x109/L). Therefore, we wonder if this patient developed seropositive ABPA following sensitisation and repeated exposure to Aspergillus species. What is interesting in the presented case is the absence of pre-existing respiratory disease, as ABPA does not usually present as an acute primary condition. ABPA is more often found in patients with asthma and cystic fibrosis, and certainly the presence of asthma is considered essential for the diagnosis of classical ABPA; however it is not infrequent that it is reported in individuals without a past history of asthma.3–5
- © Royal College of Physicians 2016. All rights reserved.
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