Q:

5/7/2014
I have a question about a 17 year-old African American girl Moderate persistent asthma, Allergic Rhinitis (mold), Allergic Fungal sinusitis, Chronic Sinusitis, nasal polyp s/p surgery (2012), GERD, ASA desensitization (11/27/2013). Her case is as follows.

11/21/2011
She was presented for evaluation of possible asthma. The patient had a history of wheezing and bad asthma as a child from about the age of 3 years until 5 years but none after. Her symptoms started in July 2011. Was seen by A/I in town, had already received two rounds of steroids and antibiotics since July. At our clinic she was diagnosed with Moderate persistent asthma (clinically significant bronchospasm reversibility), chronic Rhinitis and GERD and was started on Symbicort, cetirizine, Nasacort and omeprazole. Allergy skin prick test for most common inhaled aeroallergen was negative.

07/13/2012
Nasal polyp was found and she had many asthma exacerbations requiring oral steroid and ER visits. Continued to have uncontrolled upper airway symptoms despite nasal wash, nasal spray and antihistamine use. Singulair was added. Referred to ENT.

9/6/2012
CT scan of sinuses showed Extensive pan sinus disease involving the bilateral maxillary, ethmoid, sphenoid, and frontal sinuses with hyperdense material filling much of the right maxillary antrum raising the question of fungal involvement.

10/08/2012
Chronic sinus illness with failure of medical management, exacerbation of pulmonary disease, and radiographic evidence of chronic sinusitis which has remained persistent despite medical management, surgery was done with following findings. Significantly inflamed, edematous nasal mucosa bilaterally. Polypoid changes to obstructive bilateral middle turbinates. Thick, tenacious fungal-appearing allergic mucin of the bilateral maxillary sinuses.

11/04/2012
Allergy skin testing for mold with good histamine response and positive diluent response. Her interpretation was adjusted based on size of diluent response, showed sensitivity to cladosporium. Intradermal testing was done with histamine, diluent, Mold mix I (Alternaria tenuis, Aspergillus niger, Helminthosporium sativum, Hormodendrum bordei, and Penicillium notatum) and Mold mix 2 (Curvularia spicifera, Fusarium monidiforme, Mucor plumbeus, Pullularia pullulans, and Rhizopus nigricans), aspergillus fumigatus and Epicoccum showed sensitivity to epicoccum, mold mix I and II. Fungus culture - no growth to date.

CBC with Diff - 6.8>12.6/39.3<337, S 39.3, L 47.7, M 7.1, E 4.7, B 1.2 ANC 2672, ALC 3243, AEC 319

02/2013
She reported she has always taken Advil for her headache and menstrual cramp but never had trouble before but 2 weeks ago, she took Advil for her headache and within 10 minutes, her eyes started swelling up, itchy eyes, runny nose, hard to swallow, abdominal cramps and shortness of breath for which she took Claritin and used her inhaler which helped her. She denied any lip, tongue and throat swelling, hives, red flushed skin, change in voice, nausea, diarrhea or CVS symptoms. She ate her lunch at noon and this happened at 5 PM. She denied any insect sting.

To control her asthma, Q var was added to Symbicort. Her aspirin challenge was not able to be carried out as she would get asthma flare frequently.

08/2013, AIT for mold was started and reached maintenance dose in 02/2014.

Aspirin challenge was planned and was able to do it finally in November 2013. She had reaction to aspirin, converted to desensitization and was placed on 650 mg PO BID. Patient never reported remarkable improvement in her nasal or asthma symptoms. But if we look at past 6 months history, has not required any oral steroid burst as well as repeat CT by ENT is improved for polyp.

All literature suggests usually patients get remarkable improvement after even one month of aspirin therapy, some says trial up to six months is okay to see if symptoms improve. She is about to finish 6 months therapy, if symptoms are not improved per her, do I continue aspirin or stop it as it did not work for her? If continue then to bring her dose down to 350 mg PO BID and stay on it for one year and then stop? All literature compares data for one year of therapy. What is the end point even if aspirin therapy works for her?

A:


Thank you for your inquiry.

First of all, I think that you have done due diligence in caring for this patient, and there may be little else to offer. However, I am going to refer your inquiry to Dr. Ronald Simon, who is a nationally known expert in aspirin-exacerbated respiratory disease (AERD). When we receive his response, we will forward it to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

We received a response from Dr. Ronald Simon regarding your inquiry. Thank you again and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. Ronald Simon:
The easy question to answer is that aspirin treatment of AERD patients is for life. We've never seen a remission and except for rare patients, their disease flares when they come off ASA (for a variety of reasons). Also simple, we usually reduce the dose after three months (six at most) if the patient is doing well.

Now that's where I'm having difficulty. Despite a beautifully laid out history, it does not state the symptoms have improved (despite what sounds like an unusually long spell without a burst of pred & improved sinus CT). She has so many disorders that could be contributing to those symptoms (AR, AFS, GERD & AERD), perhaps if one parses them out one could discern which of those disorders might be responsible.

She would be very young to have AERD. I would like to know more about the criteria by which the challenge was deemed positive as the historical reaction sounds more like GERD or the pill getting stuck in the esophagus on the way down. Thus the dysphagia and then a torrent of epiphoria & rhinorrhea as the brain tried to get it up & out.

With a negative fungal sinus culture and what sounds like an interpretable + PST to clado and then pan positive mold ID's I must admit to questioning the diagnosis of AFS too. I wonder if a total IgE was done.

If that's too much for an Ask the Expert response, you could simply include the one statement above on ASA dosing and a suggestion in this case, to reduce he dose to 325 bid (she wrote 350 but I think it must be a typo) and see how she does over the following 3-6 months and if no deterioration then 325 qd for 3-6 months & if still not, then D/C. I suggest only because if you simply D/C ASA and her clinical course suffers, she would need to be re-challenged and desensitized, but that is certainly an option. Hope all that helps.

Ronald Simon, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology