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A 42-year-old female comes to your office with a history
of asthma that has been difficult to control. She
relates symptoms that have been worsening over the
last 4–6 weeks. She received two courses of oral corticosteroids
during that time. Her symptoms improved
with this therapy but quickly returned after completing
the steroids. She denies fever, chills and night sweats,
but complains of a chronic cough productive of
brownish-colored sputum. Her review of systems is
otherwise negative. She is a homemaker in a suburban
area and has no pets. Physical examination reveals
wheezing throughout all lung fields, but is otherwise
within normal limits. Spirometry values are decreased
from her baseline. Laboratory evaluation includes normal
CBC (aside from a very few eosinophils), normal
C-reactive protein, and an elevated IgE level of 1,250
ng/mL. A high-resolution CT scan of the chest reveals
central bronchiectasis.
What is the most likely diagnosis?
A) Hypersensitivity pneumonitis.
B) Acute eosinophilic pneumonia.
C) Allergic bronchopulmonary aspergillosis.
D) Bacterial pneumonia.
E) Churg-Strauss vasculitis.

Which of the following would be the next best
step in confirming the diagnosis?
A) Sputum cultures.
B) Transbronchial biopsy.
C) Methacholine challenge.
D) Allergy skin testing for Aspergillus species.
E) p-ANCA.

The most appropriate treatment would include
which of the following?
A) Antibiotics.
B) Oral corticosteroids.
C) Leukotriene receptor antagonist.
D) Levalbuterol.
E) Inhaled ipratropium bromide.

ACC

C
D
B

Dx Allergics broncop aspergillosis then...-c-d-b-

yissi and berserk....u both are right.
as you can notice, it is good idea to cover the topic with more than one question inregard to specific disease, this way, it will be review for that topic.


Discussion
The correct answer is C. This patient’s history points
to the diagnosis of allergic bronchopulmonary
aspergillosis (ABPA), which is characterized by the
presence of severe asthma, brownish mucus plugs,
peripheral eosinophilia, elevated serum IgE, and central
bronchiectasis. Answer A is incorrect but a bit
tricky. First, there is no history of exposure to a
causative agent. Second, let’s focus on symptoms. Constitutional
symptoms are present in the acute form of
hypersensitivity pneumonitis (eg, fever). However, they
need not be present in the subacute and chronic forms
of the disease. So, based on symptoms, this could be
hypersensitivity pneumonitis. However, the radiologic
findings of hypersensitivity pneumonitis would include
interstitial lung disease, rather than central bronchiectasis.
Therefore, this is not likely hypersensitivity pneumonitis.
Answers B and D are incorrect. Note that she
has no significant constitutional symptoms that might
be more typical of acute eosinophilic pneumonia or
bacterial infection. You would also expect an infiltrate
on the chest CT. Answer E is incorrect. Churg-Strauss
vasculitis is characterized by transient patchy interstitial
infiltrates, fever, weight loss, elevated sedimentation
rate, abnormal liver enzymes, and a peripheral
blood eosinophilia >1,000/micrograms/L. Remember
that this patient has a normal CBC. Extrapulmonary
manifestations distinguish this entity from other
eosinophilic conditions.

Discussion
The correct answer is D. Most, but not all of the following
criteria need to be present in order to make the
diagnosis of ABPA (Table 3–9). Transbronchial biopsy
is unnecessarily invasive, and the other tests will not
help to confirm the diagnosis.

Discussion
The correct answer is B. Oral corticosteroids are
the treatment of choice for ABPA. Patients are typically
treated for several months with tapering doses
rather than short courses of steroids. Serum IgE
levels and chest x-rays are used to monitor response
to treatment.

this is the table
Table 3–9 CRITERIA FOR THE DIAGNOSIS
OF ALLERGIC BRONCHOPULMONARY
ASPERGILLOSIS (ABPA)
• Asthma
• Central bronchiectasis
• Elevated total serum IgE
• Immediate skin test reactivity to Aspergillus
• Elevated serum specific IgE and/or IgG to Aspergillus
fumigatus
• Peripheral blood eosinophilia
• Pulmonary infiltrates

yes sami.......it really covers extensively...and ur posting ques subject wise is an organized way of doin things....

thank u so much. I appreciate ur Qs a lot. You provide us other kind of qq, at leat different of usmleworld. good job : )