Q:

7/25/2013
I have a 5 year-old with difficult to control asthma. On Flovent 220 2 puffs BID and singulair 4 mg QD with several prednisone bursts this year. IgE 4327, absolute eos 500, positive IgG to alternaria, cladosporium, aureobasidium, phoma spp and pigeon. Skin test positive to alternaria only. CXR - No bronchiectasis or infiltrates. Thus far he appears to be severe asthma with fungal sensitization (SAFA).

Questions: 1. Could this be APBmycosis? 2. Or seropositive ABPA-like? 3. In patients with seropositive ABPA what is the concensus in regards to prolonged treatment with oral steroids like APBA. Can it or does it prevent development of bronchiectasis? Or is controlling the asthma clinically sufficient. Thank you.

A:

Thank you for your inquiry.

I am going to request a response to your inquiry from Dr. Brad Chipps who is a pediatric pulmonologist and allergist-immunologist specializing in the care of difficult cases of pediatric asthma as well as cystic fibrosis. When we receive Dr. Chipps’s response, we will forward it to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

We received a response from Dr. Bradley Chipps. Thank you again for your inquiry and we hope this response is helpful to you.
 
Sincerely,
Phil Lieberman, M.D.
 
Response from Dr. Bradley Chipps:
This is a very complicated case, however, I will not have one answer without further testing.

1. If any question about PMDI technique change to Foradil 12 mg + budesonide 1 mg BID in nebulizer. I would discontinue FP as 880mcg has significant systemic effect. If MDI technique is good- Symbicort 160 2 puffs BID.

2. I would recommend the following laboratory studies- Sweat test if not done. ImmunoCap for aspergillus fumigates and teris. Also, IgGAM, Vitamin D-250H, cortisol level.

3. Spiro and FeNO if possible

4. Bronchoscopy with BAL and culture for bacteria AFB and fungus. Appropriate directed therapy after result

5. If BAL positive for aspergillus then Chest CT.

I have attached articles that may be helpful. I would be glad to consult after results are available.

When to suspect and work up allergic bronchopulmonary aspergillosis

Special problems of severe asthma in childhood

Thanks
Bradley E. Chipps, MD

AAAAI - American Academy of Allergy Asthma & Immunology