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A6550 - When Uncontrolled Asthma Isn’t Uncontrolled Asthma
Author Block: R. Westman; Pulmonary and Critical Care, The Ohio State University, Columbus, OH, United States.
Background:Asthmatics with persistent respiratory symptoms are commonly seen in outpatient practice. Most commonly this is related to poor control of their underlying asthma. However, when a patient’s therapy has been maximized and they remain uncontrolled, it’s important to consider other etiologies of their persistent respiratory symptoms. Case:The patient is a 57 year old male with a history of moderate persistent asthma. His asthma had been well controlled on inhaled corticosteroids for several years. Over the past three months, the patient was seen in the emergency department on four separate occasions for worsening cough, wheezing and shortness of breath. He was treated with oral corticosteroids with improvement in his symptoms. However, upon discontinuation of the corticosteroids his symptoms returned. He was evaluated in the Pulmonary office for further evaluation of his uncontrolled asthma. His vital signs were notable for an oxygen saturation of 90% on room air. His lung examination was notable for expiratory wheezes. Nasal exam was normal. Spirometry showed an FEV1 2.29L (64% predicted), FVC 4.14L (89% predicted) and an FEV1/FVC of 55%. A CT chest showed bilateral, upper lobe predominant, subpleural and peribronchovascular ground glass opacities. A bronchoscopy with bronchoalveolar lavage (BAL) was performed and notable for an eosinophil count of 66% with negative cultures. His labs were notable for an absolute eosinophil count of 1100, negative ANCA screen, negative Strongyloides antibody and an IgE level of 13 IU/ml. He was subsequently diagnosed with Chronic Eosinophilic Pneumonia (CEP). He was started on a prolonged course of oral corticosteroids with resolution of his ground glass opacities on CT chest and improvement in both his lung function and his respiratory symptoms. Discussion:Chronic Eosinophilic Pneumonia (CEP) is an idiopathic disorder characterized by accumulation of eosinophils in the interstitial and alveolar spaces of the lung. Patients diagnosed with CEP commonly have a prior history of asthma. Patients often present with cough, dyspnea, weight loss and fevers for several weeks to months. Diagnosis is based on clinical presentation, findings on chest imaging, an elevated eosinophil count on BAL and ruling out other etiologies. The mainstay of therapy is a prolonged course of corticosteroids and relapses are common. In patients with persistently uncontrolled asthma, it remains important to consider and evaluate for alternative diagnoses including Chronic Eosinophilic Pneumonia.