Unusual presentation of a recurrent asthmatic with bronchiectasis on multiple computed topographies

Recurrent treatment resistant asthma in high risk patient populations may be the inciting factor that leads to further evaluation of other contributing etiologies of a patient’s symptoms. Allergic bronchopulmonary Aspergillus (ABPA) is primarily an immunologic response that is most commonly seen in asthmatics and cystic fibrosis patients. Common presentation will include symptoms of hemoptysis, fever, weight-loss, malaise as well as transient and fleeting pulmonary opacities and bronchiectasis on imaging. ABPA is classified as an allergic respiratory mycosis against Aspergillus fumigatus, and has a higher incidence seen in asthmatic specialty clinics as well as those in the intensive care unit.

The pathogenesis of ABPA is not fully understood, but is thought to be due to difficulty with clearance of the airways in genetically predisposed patients as well as T-helper 2 cell immune response. In these genetically predisposed patients, they are unable to clear the Aspergillus fumigatus conida from their airways which subsequently germinates into hyphae leading to a activation of the adaptive immune response and release of both chemokines and cytokines. This ultimately leads to development of a large inflammatory response with mast cell degranulation, recruitment of eosinophils and neutrophils, and the development of the characteristic immunologic response seen in ABPA as well as progression to bronchiectasis and pulmonary fibrosis.