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A Case of Asthma?Bronchospasm?Hypersensitive Pneumonitis?
Mr D is 46 year old male;
• Non smoker
• Works as a builder
• Is a bird owner (species unknown)
• Previous exposure to fibreglass
• Intermittent eczema
• Family history of asthma
PATIENT HISTORY:
• Logan Emergency Department admission 20/05/2013 and 26/05/2013.
• Productive cough, wheeze, afebrile, pain on inspiration and progressive
shortness of breath.
• Current respiratory medications: Spiriva, occasional ventolin. Amoxycillin given by
GP.
• No history of respiratory function tests.
• C-Reactive Protein: 40mg/L, elevated. Protein produced in the liver, increases in
the presence of inflammation.
• Haematology and blood gases normal: PO2; 76mmHg, PCO2; 42mmHg.
• CT: The lung volumes are preserved. Coarsened bronchovascular markings are
seen, particularly in the left base, likely affecting a bronchial inflammatory process.
No collapse or consolidations is seen and the pleural cavities are clear.
• Discharged with outpatient respiratory review.
• Lung function 29/10/2013, showed lung function within normal limits with no acute
response to bronchodilator. Reduction in FRC.
29/10/2013 Respiratory Function Test.
•
7/05/2014 Methacholine Bronchoprovocation Challenge was negative, only -7%
reduction in FEV1 at final dose (8mg). No significant hyper-responsive airways
response or response to bronchodilator and no evidence of airflow obstruction.
Spirometry shows a global increase compared with 29/10/13. 15% increase in
FEV1, 9% increase in FVC.
LOGAN HOSPITAL EMERGENCY DEPARTMENT JUNE 2015:
• Logan Hospital Emergency Department presentation on 22/06/2015.
• Respiratory distress – Productive cough, wheeze, rash, afebrile.
• Recently cleaned his aviary.
• Chemical Pathology: Elevated Neutrophils (12.71x109/L) and White blood cells
(14.9 x109/L). C-Reactive Protein: 25mg/L, elevated.
• ECG: Normal Sinus Rhythm, 78bpm.
• SpO2 on room air: 92%.
• CT: Interstitial changes seen in the left lower zone behind cardiac shadow. No
pleural effusion or pneumothorax. The cardiomediastinal contour was normal.
• Blood IgE insignificant 77 (kU/L).
• HRCT: Both upper zones show a subtle increase in “ground glass” nodularity (35mm). The lower zones show widespread bronchial wall thickening, with some
areas of mucus impaction. Upper zone centrilobular nodules which are not specific
but can be seen in hypersensitivity pneumonitis. General evidence of bronchial wall
thickening consistent with bronchial inflammation.
• Spirometry 22/06/2015 showed severe airflow obstruction and a FeNO: 46ppb,
indicating possible eosinophilic airway inflammation. Note also reduced FVC –
can’t exclude a restrictive ventilatory defect without static lung volumes.
• Spirometry on 23/06/2015 showed moderate airflow obstruction, likely due to
reduced bronchospasm. Cough was reduced but still present.
• Skin Allergen testing 23/06/2015 was positive to Dust Mite (D.pteronyssinus)
7x7mm. Histamine 5x5mm.
• Immunology: RAST House Dust Mite Mix – Very low positive. Anti-neutrophil
cytoplasmic antibody (pANCA, cANCA) negative.
22/05/2016 Spirometry and FeNO:
24/06/2015 Repeat Inpatient RFT:
•
•
Bronchoscopy performed 2/07/2015 to investigate radiologic abnormality, cough
and nodular infiltrates: “Collapsible trachea and entire bronchial tree. Left and right
main bronchus collapsed by over 50%, suggestive of excessive dynamic airway
collapse. EDAC – present typically in obstructive airways disease patterns, e.g.
COPD and asthma. Histopathology-Biopsy; sections show lung parenchyma and
scant detached respiratory epithelium. No granulomas or eosinophils present.
There is no evidence of inflammation, atypia or malignancy in examined sections”.
Mildly elevated mycoplasma serology 640 Tot-Ab (PA) (M. Pneumoniae), and
repeat reading was 320 Tot-Ab (PA), indicating possible mycobacteria infection.
Avian precipitins negative.
Patient discharged with; Roxithromycin, Cefuroxime, Prednisolone, Alvesco,
Spiriva and Ventolin.
OUTPATIENT FOLLOW UP:
• Respiratory function test 16/09/2015 showed lung function within normal limits and
no acute response to bronchodilator, reduced FRC. FeNO: 29ppb may indicate
possible eosinophilic airway inflammation, noting Alvesco was self administered
<12hours prior testing. SpO2: 97%.
• Negative Mannitol Bronchoprovocation Challenge 18/09/2015, with no evidence of
airflow obstruction nor hyper-responsive airways on this occasion, suggesting
Asthma unlikely. Normal Spirometry, 315mg Mannitol administered with only -3%
reduction in FEV1 from baseline and no significant response to bronchodilator.
• Clinic follow up on 22/09/2015 with improvement in symptoms, cessation of
antibiotics and prednisolone. Mr D remains Alvesco with some relief.
• Clinic follow up on 31/05/2016. Some hayfever noted, otherwise asymptomatic.
Spirometry within normal limits. Mr D is for follow up Spirometry and FeNO in 3
months.
16/09/2015 - Outpatient RFT:
POINTS TO CONSIDER:
Patient has had both negative direct and indirect bronchoprovocation challenge test results
with different positive and negative predictive power, suggesting asthma unlikely. While
5% of the asthmatic population can produce negative bronchoprovocation challenge
results outside the normal 95% CI, Mr D has produced negative results to both direct and
indirect bronchoprovocation test.
FeNO measurements suggest airway eosinophilic airway inflammation may be present.
There was a 37% reduction in FeNO on 16/09/2015, suggesting airways may have been
sensitive to inhaled corticosteroid therapy. Noting patient had recently used Alvesco within
recommended withholding period for the most recent FeNO laboratory visit.
The bronchoscopy on 2/7/2015 had identified mycoplasma (M.Pneumoniae), but had ruled
out inflammation and malignancy.
A Repeated HRCT performed (16/09/2015): Significant improvement in centrilobular
nodularity in both lobes. No bronchiectasis, consolidation or collapse identified. These
results suggest mycoplasma infection resolved.
Concluded: “Reactive airways with evidence of severe bronchospasm June 2015, possibly
secondary to mycoplasma (M. Pneumoniae) infection.”
Mr D has been referred for repeat Spirometry and FeNO in August 2016. FEV1 trend to
date;
FEV1
FEV1 Trend
+3
6.00
+2
+1
4.00
-1
-2
3.00
-3
2.00
FEV1Mean
1.00
Linear (+3)
16
16
29
/0
4/
15
29
/0
1/
15
29
/1
0/
15
29
/0
7/
15
29
/0
4/
14
29
/0
1/
14
29
/1
0/
14
29
/0
7/
29
/0
4/
14
Linear (+2)
29
/0
1/
13
0.00
29
/1
0/
(Litres)
5.00
Linear (+1)
Linear (- 1)
Linear (- 2)
Dates
Linear (- 3)