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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 67  |  Issue : 2  |  Page : 195-197

Allergic bronchopulmonary aspergillosis mimicking miliary tuberculosis


1 Department of Internal Medicine, Respirology and Critical Illness Division, Universitas Indonesia, Rumah Sakit Cipto Mangunkusumo, Depok, Indonesia
2 Department of Internal Medicine, Allergy and Immunology Division, Universitas Indonesia, Rumah Sakit Cipto Mangunkusumo, Depok, Indonesia

Date of Submission26-Feb-2018
Date of Acceptance03-May-2018
Date of Web Publication14-Jun-2018

Correspondence Address:
Gurmeet Singh
Jl. Diponegoro No. 71, Central Jakarta 10430
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejcdt.ejcdt_29_18

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  Abstract 

Tuberculosis (TB) continues to be a major global health problem, especially in developing countries such as Indonesia. TB makes the individual more susceptible to other diseases caused by other microorganisms. Allergic bronchopulmonary aspergillosis (ABPA) is usually a progressive disease, occurs in patients with hypersensitivity toward Aspergillus fumigatus, and is found almost exclusively in asthma and cystic fibrosis patients. The clinical manifestations and radiologic findings of ABPA often mimic other pulmonary diseases. This case report illustrates a 35-year-old women who was initially diagnosed with miliary TB, but was later diagnosed with ABPA after further examinations (immunoglobulin E and thoracic computed tomography scan). After treatment with anti-TB drugs, itraconazole, and methylprednisolone for 2 weeks, the patient felt resolution of symptoms. Significant changes were in the chest radiography and the immunoglobulin E level reduced considerably.

Keywords: allergic bronchopulmonary aspergillosis, antifungal, tuberculosis


How to cite this article:
Singh G, Fauzi NB, Widhani A. Allergic bronchopulmonary aspergillosis mimicking miliary tuberculosis. Egypt J Chest Dis Tuberc 2018;67:195-7

How to cite this URL:
Singh G, Fauzi NB, Widhani A. Allergic bronchopulmonary aspergillosis mimicking miliary tuberculosis. Egypt J Chest Dis Tuberc [serial online] 2018 [cited 2023 Feb 1];67:195-7. Available from: http://www.ejcdt.eg.net/text.asp?2018/67/2/195/234175


  Introduction Top


In 2016, global tuberculosis (TB) incidence was 10.4 million, with most cases occurring in South-East Asia (45%) [1]. In Indonesia, there were as much as 298 128 cases, with the highest prevalence in West Java [2]. Allergic bronchopulmonary aspergillosis (ABPA) is a progressive disease and occurs in patients with hypersensitivity toward Aspergillus fumigatus in the airways and is usually found exclusively in asthma or cystic fibrosis patients [3],[4]. Studies have been conducted to estimate the epidemiology of ABPA [5]. In Indonesia, ABPA is often misdiagnosed and specific examinations are not widely available. This case report aims to shed light on the diagnosis and treatment of ABPA.

Case illustration

A 35-year-old women presented to a primary healthcare center with complaint of breathing difficulty causing restricted physical activities. She feels dyspneic after walking for less than 100 m. At the said health center, she was diagnosed with dyspepsia and lung infection and was given both chemical and herbal drugs. The patient has a history of bronchitis and hepatitis, and also frequent episodes of atopy symptoms (sneezing and watery eyes in the morning). She denied any history of asthma, cystic fibrosis, and negative for TB contact.

After a month of treatment, symptoms did not resolve and patient experienced other symptoms such as fever, shivering, and productive cough with greenish sputum for a week. The patient was hospitalized at a nearby hospital. Physical examinations found bilateral crackles and wheezing in both lungs; laboratory tests showed a high level of eryhtrocyte sedimentation rate (ESR) (60 mm/h), and chest radiography was suggestive of miliary TB as shown in [Figure 1].
Figure 1 Chest X-ray taken on initial assessment showing infiltrates on the upper and middle right lung field and miliary infiltrates with laterobasal consolidation on the left lung, suggestive of left pleural effusion.

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Patient was put on anti-TB drugs (first category) for 2 weeks without any significant resolution of symptoms. The patient sought second opinion to our national referral hospital and was evaluated for ABPA [lung computed tomography (CT) scan and immunoglobulin E (IgE) examination]. IgE levels were significantly elevated (3139 ng/ml) and CT scan revealed infiltrates on almost all the areas of the right and left lungs, bronchiectasis on segments 1, 2, 3, 9, 10, and multiple bullae on the third lateral segment with pleural effusion in the left lung ([Figure 2]).
Figure 2 Thoracic CT-scan taken 2 weeks after anti-TB treatment showing extended infiltrates on both lungs with bronchiectasis on segments 1, 2, 3, 9, and 10 and multiple bullae on right lateral segment 3 and left pleural effusion suggestive of a specific process (TB).

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The patient underwent bronchoscopy and further workup for ABPA (blood galactomannan). All examinations were positive for aspergillosis. The patient was diagnosed with ABPA and was given 200 mg of itraconazole (taken twice daily), 8 mg of methylprednisolone taken once in 2 days, and anti-TB regimens were continued.

On further evaluation after 2 weeks, patient’s symptoms, lab tests, and lung CT scan showed resolution (the IgE level was decreased to 1932 ng/ml), but still has occasional productive cough.

The patient was advised to stop ATT after 6 months, and to continue itraconazole and steroids treatment for a total 6 months. The patient continues routine follow-up in our outpatient clinic.


  Discussion Top


The patient was a 35-year old women with miliary TB. However, after further examinations, she was diagnosed with ABPA. Often, confusions of diagnosis like this happen due to the similarities of clinical manifestations and radiologic findings. Allergic bronchopulmonary aspergillosis is almost exclusively found in patients with asthma or cystic fibrosis. This patient had no history of asthma or cystic fibrosis, only frequent episodes of atopy such as sneezing and watery eyes in the morning.

Generally, ABPA clinical manifestations include worsening of asthma or cystic fibrosis, with occasional expectorations of golden-brown sputum plugs [6]. Since the patient had no asthma or cystic fibrosis, it was difficult to exactly distinguish ABPA at initial presentation. Symptoms that the patient experienced were fever, dyspnea, and productive cough with greenish sputum, with physical examinations showing crackles and wheezing, which are commonly found in every lung infection. The patient was diagnosed with miliary TB and was put on anti-TB drugs. After 2 weeks of treatment, symptoms of TB should have resolved, but the patient felt no resolution to her symptoms. The patient underwent examinations for ABPA, namely total IgE serum and thoracic CT scan. The patient’s IgE level was 3139 IU/ml and usually the cutoff for IgE to be considered suggestive of ABPA is above 1000 IU/ml. Patient’s thoracic CT scan showed bronchiectasis on segments 1, 2, 3, 9, and 10. Thoracic CT scan findings suggestive for ABPA are central bronchiectasis in multiple lobes [6],[7].

Initial treatment given to the patient included anti-TB drugs, 200 mg of itraconazole given twice daily, and 8 mg of methylprednisolone taken once in 2 days [8]. Anti-TB treatment was continued due to initial diagnosis of miliary TB, Indonesia is endemic for TB, and aspergillosis is a comorbid for TB. Studies have found drug interactions between rifampicin and itraconazole, where it is suggested that rifampicin reduces the serum concentration of itraconazole, therefore reducing its antifungal effects [9],[10]. Upon follow-up at 2 weeks of treatment, the patient felt resolution of almost all of her symptoms. The patient’s IgE levels also reduced from 3139 to 1932 IU/ml. From chest radiography, the resolution can be seen as in the figures.


  Conclusion Top


Allergic bronchopulmonary aspergillosis should be considered as a differential diagnosis difficult to treat in TB patients.

Acknowledgements

The authors thank the patient for her cooperation during the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Global Tuberculosis Report 2017. World Health Organization. 2017. p. 21–22. Available from: www.who.int/tb/publications/global_report/en  Back to cited text no. 1
    
2.
Data Dan Informasi. Profil Kesehatan Indonesia 2016. Kementerian Kesehatan Republik Indonesia. p. 114–117. Available from: www.depkes.go.id  Back to cited text no. 2
    
3.
Patterson K, Strek ME. Allergic bronchopulmonary aspergillosis. Proc Am Thorac Soc 2010; 7:237–244.  Back to cited text no. 3
    
4.
Latge JP. Aspergillus fumigatus and Aspergillosis. Clin Microbiol Rev 1999; 12:310–350.  Back to cited text no. 4
    
5.
Denning DW, Pleuvry A, Cole DC. Global burden of allergic bronchopulmonary aspergillosis with asthma and its complication chronic pulmonary aspergillosis in adults. Med Mycol 2013; 51:361–370.  Back to cited text no. 5
    
6.
Shah A, Panjabi C. Allergic bronchopulmonary aspergillosis: a perplexing clinical entity. Allergy Asthma Immunol Res 2016; 8:282–297.  Back to cited text no. 6
    
7.
Tillie-Leblond I, Tonnel AB. Allergic bronchopulmonary aspergillosis. Allergy 2005; 60:1004–1013.  Back to cited text no. 7
    
8.
Tracy MC, Okorie CUA, Foley EA, Moss RB. Allergic bronchopulmonary aspergillosis. J Fungi (Basel) 2016; 2:E17.  Back to cited text no. 8
    
9.
Swart A, Harris V. Drug interactions with tuberculosis therapy. Contin Med Educ 2005; 23:56–60.  Back to cited text no. 9
    
10.
Moon SM, Park HY, Jeong BH, Jeon K, Lee SY, Koh WJ. Effect of rifampicin and rifabutin on serum itraconazole levels in patients with chronic pulmonary mycobacterial infection.Antimicrob Agents Chemother 2015; 59:663–665.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]


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