Allergic Bronchopulmonary Aspergillosis and Fungoses

Prevalence of Aspergillus hypersensitivity and allergic bronchopulmonary aspergillosis in patients with bronchial asthma at a tertiary care center in North India

Background:

The prevalence of Aspergillus hypersensitivity (AH) and allergic bronchopulmonary aspergillosis (ABPA) has been variably reported. Systematic data regarding Aspergillus sensitization and ABPA are lacking from this part of the country.

Objectives:

The aim of this study was to evaluate the prevalence of AH and ABPA in Uttar Pradesh.

Setting and Design:

This was prospective observational study. All patients attending outpatient Department of Pulmonary Medicine of our institute were included in the study.

Subjects and Methods:

Consecutive asthmatic patients underwent screening for ABPA using Aspergillus skin test (AST). Those showing a positive response to AST were further evaluated for ABPA.

Results:

During the study, 350 patients (192 males, 158 females, mean ± standard deviation age: 38.3 ± 12.8) were screened with AST. One hundred and twenty-three patients (35.1%) were tested positive for AST and 21.7% of patients were diagnosed as ABPA.

Conclusions:

A high prevalence rate of ABPA was observed at our chest clinic. Although comparable with published data from other tertiary centers, it does not represent the true prevalence rates in asthmatics because of high chances of referral bias.

Allergic bronchopulmonary aspergillosis

There remains a lack of agreement on diagnostic criteria and approaches to treatment of patients with allergic bronchopulmonary aspergillosis (ABPA). The results of a survey of American Academy of Allergy, Asthma, & Immunology members regarding these 2 issues are presented and compared for concordance with published recommendations. The literature was reviewed for pertinent reports, and an electronic survey was conducted of American Academy of Allergy, Asthma, & Immunology members and fellows regarding diagnostic criteria, numbers of patients evaluated for ABPA, and treatment approaches. From 508 respondents to the survey sent to 5155 US physicians in the American Academy of Allergy, Asthma, & Immunology database of members and fellows, 245 health professionals (48%) had treated at least 1 patient with ABPA in the previous year. For the diagnosis of ABPA, there was a difference in the threshold concentration of total serum IgE because 44.9% used ≥417 kU/L, whereas 42.0% used ≥1000 kU/L. Analysis of these findings suggests that ABPA might be underdiagnosed. With regard to pharmacotherapy, oral steroids were recommended for 97.1% of patients and oral steroids plus inhaled corticosteroids plus antifungal agent were used with 41.2% of patients. The armamentarium for treatment of ABPA includes oral corticosteroids as the initial treatment with inhaled corticosteroids used for management of persistent asthma. Azoles remain adjunctive. Published experience with omalizumab has been limited.

Duplication in CHIT1 gene and the risk for Aspergillus lung disease in CF patients

BACKGROUND

Aspergillus often persists in the respiratory tract of patients with Cystic Fibrosis (CF) and may cause allergic broncho-pulmonary aspergillosis (ABPA). Chitinases are enzymes that digest the chitin polymer. Plants use chitinase as a defense mechanism against fungi. Chitotriosidase (CHIT1) is the major chitinase in human airways. Variation in the coding region with 24-bp duplication allele results in reduced CHIT1 activity. Recently, CHIT1 duplication heterozygocity was found in 6/6 patients with severe asthma and fungal sensitization (SAFS).

AIM

Our aim was to evaluate the link between CHIT1 duplication in CF patients and the predisposition to Allergic broncho-pulmonary mycosis (ABPM) or persistent Aspergillus positive sputum (APS).

PATIENTS AND METHODS

CHIT1 duplication was assessed in three CF groups. Group 1: patients who had neither ABPM nor APS in the past (control group). Group 2: patients with persistent APS (≥2/year), without ABPA. Group 3: patients with current or past ABPM.

RESULTS

Forty patients with CF were included in the analysis, CHIT1 duplication heterozygocity was found in 3/6 (50%) of the patients in the ABPM group, 3/12 (25%) in the APS group, and 7/22 (31.8%) in the control group (P > 0.05). Eleven patients carried W1282X mutation, 90.9% were negative for CHIT1 duplication, five of them were homozygous for W1282X; none of them had CHIT1 duplication or ABPM.

CONCLUSIONS

CHIT1 duplication is not found in all CF patients with ABPM in contrast to patients with SAFS. These results suggest that CHIT1 duplication cannot be the sole explanation for Aspergillus positive sputum in CF patients.

[Pulmonary allergic reactions]

Allergic diseases of the lungs may affect the airways, the pulmonary parenchyma and the pulmonary vessels. The most relevant representatives are allergic asthma, hypersensitivity pneumonitis, bronchopulmonary aspergillosis and the Churg-Strauss syndrome. The type of allergic reaction and the pathophysiological consequences vary considerably between these entities. New drugs target specific mechanisms based on new insights into the pathogenetic processes of the underlying disease.

Severe asthma with fungal sensitization: a case report and review of literature

There is a substantial body of evidence supporting an association between asthma severity and fungal exposure and sensitization. Fungal allergens are a recognized risk factor for severe asthma. We describe the case of a 44-year-old asthmatic whose asthma control deteriorated after moving to a new flat with walls covered in mould. Allergic bronchopulmonary aspergillosis was excluded. Although sensitization to Candida was demonstrated by a positive Candida-specific radioallergosorbent test, the patient did not entirely satisfy the criteria for a diagnosis of allergic bronchopulmonary candidiasis. The patient's asthma control improved after engaging in a monthly washing regimen of the walls. This case further demonstrates the association between fungal sensitization and asthma severity. The term severe asthma with fungal sensitization has been recently coined to describe this phenomenon.

Cross-reactivity among fungal allergens: a clinically relevant phenomenon?

Atopic patients suffering from allergic asthma, allergic rhinitis, or atopic eczema often have detectable levels of serum IgE antibodies to fungi. Although the association between fungal sensitisation and different forms of allergic diseases, including allergic asthma and life-threatening allergic bronchopulmonary aspergillosis, is well established, the clinical relevance of cross-reactivity among different fungal species remains largely unknown. Recent progress in molecular cloning of fungal allergens and the availability of more than 40 completely sequenced fungal genomes facilitates characterisation, cloning, and production of highly pure recombinant allergens, identification of homologous and orthologous allergens widespread among the fungal kingdom, in silico prediction, and experimental in vitro and in vivo verification of cross-reactivity between homologous pan-allergens. These studies indicate that cross-reactivity is an important component of fungal sensitisation.

Role of chest radiography in the diagnosis of allergic bronchopulmonary aspergillosis in adult patients with cystic fibrosis

PURPOSE

This study aimed to verify the usefulness of chest radiography in the diagnosis of allergic bronchopulmonary aspergillosis (ABPA) in adult patients with cystic fibrosis.

MATERIALS AND METHODS

Eleven patients (with a total of 14 episodes) affected by ABPA were selected from among subjects attending a Regional Cystic Fibrosis Centre. For each episode, we retrospectively reviewed the baseline chest radiographs obtained before the diagnosis of ABPA, those obtained during the course of ABPA and those obtained during follow-up. Radiographs were assessed for the presence of bronchial wall thickening, bronchiectasis, infiltrates, atelectasis, mucoid impaction, lymphadenopathy, pleural effusion and fluid levels. Radiographic findings that had appeared at the time of ABPA diagnosis and disappeared after treatment were considered related to ABPA and thus useful for a correct diagnosis of the disease. Chest radiograph abnormalities were compared with changes on the respiratory function tests [forced expiratory volume in 1 s (FEV1)] during the different stages of the disease.

RESULTS

Radiographic findings at the time of ABPA diagnosis appeared to have deteriorated in 8/14 cases when compared with the baseline films; after treatment, the radiographic findings deteriorated in 6/14 cases and improved in 6/14. The most significant among the radiographic signs considered (infiltrates and mucoid impaction) appeared at the time of ABPA diagnosis in 7/14 and 4/14 cases, respectively, and in some patients, they were also present at baseline and persisted during follow-up. FEV1 values were significantly decreased (>10%) in 9/14 cases at the time of ABPA diagnosis.

CONCLUSIONS

Our results demonstrate the limited usefulness of chest radiography in the diagnosis of ABPA in patients with cystic fibrosis. The most significant abnormalities are nonspecific and commonly seen on baseline films in cystic fibrosis without ABPA and persist after treatment in most cases.

Effect of allergic bronchopulmonary aspergillosis on lung function in children with cystic fibrosis

RATIONALE

The relationship between sensitization to Aspergillus fumigatus and progression of pulmonary function is not yet established in cystic fibrosis (CF).

OBJECTIVES

We aimed to evaluate onset of A. fumigatus sensitization and development of allergic bronchopulmonary aspergillosis (ABPA), as well as to determine the physiologic factors of lung function influencing these mechanisms in CF.

METHODS

Serial annual lung function tests performed in 122 children with CF (62 males; 60 females; age: 6-18 yr) provided data pertaining to FRC measured by plethysmography, lung clearance index, volume of trapped gas, effective specific airway resistance, and forced expiratory indices (FEV1, FEF at 50% VC). Specific IgE to recombinant A. fumigatus allergens, rAspf1 and rAspf3, served as marker for sensitization, and to rAspf4 and rAspf6 as indications for a serologic ABPA, were clinically diagnosed (Nelson criteria). By linear mixed-effect model analysis, five patient groups, (1) not sensitized and free from Pseudomonas aeruginosa, (2) intermittently P. aeruginosa colonized, (3) chronically P. aeruginosa infected, (4) sensitized, and (5) with ABPA, were retrospectively evaluated.

MEASUREMENTS AND MAIN RESULTS

A. fumigatus sensitization was best reflected by increased rAspf1+3-specific IgE levels, whereas, in most patients, sensitization was preceded by P. aeruginosa infection. Patients with ABPA demonstrated the most severe progression in all lung function parameters, and FEF at 50% VC, volume of trapped gas, and effective specific airway resistance were the best predictors (p < 0.0001). However, regarding distinction between sensitization to A. fumigatus and development of ABPA in the course of CF, chronic P. aeruginosa infection has to be taken into account.

CONCLUSIONS

Airway narrowing, gas trapping, and small airway disease are the major targets for functional derangement in ABPA.

[IgE and respiratory disease]

INTRODUCTION

IgE is known to provide the biological basis for allergy and immediate hypersensitivity. However, recent data provide some evidence that IgE responses are involved in other inflammatory processes apart from allergy, including several respiratory diseases.

STATE OF THE ART

IgE binds to mast cells and basophils but also to other inflammatory cells, which are involved in non-allergic processes. IgE has a role in antigen presentation and is implicated in a number of other immune mechanisms. In the airways, IgE plays an important role in bronchial hyperactivity, even in the absence of an allergen. Epidemiological studies have demonstrated that IgE response is related not only to allergy but also to asthma symptoms, in the presence or absence of atopy, as well as exposure to cigarette smoke. IgE response is altered in several respiratory diseases including extrinsic and intrinsic asthma and allergic bronchopulmonary aspergillosis.

CONCLUSION AND PERSPECTIVES

Since anti-IgE monoclonal antibodies are now available for administration to humans, a better understanding of the IgE response may allow the identification of novel therapeutic targets in the field of respiratory disease.

Idiopathic chronic eosinophilic pneumonia

Idiopathic chronic eosinophilic pneumonia (ICEP) is characterized by subacute or chronic respiratory and general symptoms, alveolar and/or blood eosinophilia, and peripheral pulmonary infiltrates on chest imaging. Eosinophilia is present in most cases, usually in excess of 1000/mm3. In absence of significant blood eosinophilia, a diagnosis of ICEP is supported by the demonstration of bronchoalveolar lavage eosinophilia. ICEP is typically associated with eosinophil counts higher than lymphocyte counts in the bronchoalveolar lavage. ICEP is a rare disorder of unknown cause. Its exact prevalence remains unknown. ICEP may affect every age group but is rare in childhood. It is twice as frequent in women as in men. One third to one half of the ICEP patients have a history of asthma. The mainstay of treatment of ICEP is systemic corticosteroids. Response to oral corticosteroid therapy is dramatic and has led to the consideration of corticosteroid challenge as a diagnostic test for ICEP. Nevertheless, relapses or development of severe asthma are frequent when tapering or withdrawing treatment. Long-term oral corticosteroid therapy is necessary in up to half of the patients.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) occurs in nonimmunocompromised patients and belongs to the hypersensitivity disorders induced by Aspergillus. Genetic factors and activation of bronchial epithelial cells in asthma or cystic fibrosis are responsible for the development of a CD(4)+Th2 lymphocyte activation and IgE, IgG and IgA-AF antibodies production. The diagnosis of ABPA is based on the presence of a combination of clinical, biological and radiological criteria. The severity of the disease is related to corticosteroid-dependant asthma or/and diffuse bronchiectasis with fibrosis. The treatment is based on oral corticosteroids for 6-8 weeks at acute phase or exacerbation and itraconazole is now recommended and validated at a dose of 200 mg/day for a duration of 16 weeks.

Time course of antibody response to recombinant Aspergillus fumigatus antigens in cystic fibrosis with and without ABPA

We determined follow-up levels of specific serum IgE to the recombinant Aspergillus fumigatus (A. fumigatus) allergens rAsp f 1, 3, 4 and 6 in patients suffering from cystic fibrosis (CF) with and without allergic bronchopulmonary aspergillosis (ABPA). Over a 32-month period follow-up data of 74 patients were collected. According to serology, 11 CF patients were not sensitized (CF controls), 40 were sensitized to A. fumigatus (Asp. f-sens.) and 23 patients fulfilled the serologic criteria for ABPA. Of these 23 ABPA patients 11 expressed the full clinical ABPA picture (classicABPA) and 12 failed to show sufficient relevant clinical signs (seroABPA), despite positive serology. The 23 ABPA patients had 16-18 times higher serum levels of specific IgE to rAsp f 4 and/or rAsp f 6 than those of Asp. f-sens. patients (rAsp f 4: 31.3 +/- 45 EU/ml vs. 1.9 +/- 2.2 EU/ml and rAsp f 6: 39.0 +/- 44.3 EU/ml vs 2.1 +/- 1.7 EU/ml). The combination of increased total serum IgE (>1000 IU/l) and increased specific IgE to rAsp f 4 and/or rAsp f 6 allowed to diagnose classicABPA with 100% specificity and 64% sensitivity and with a high predicted positive (100%) and a high predicted negative (94%) value. During a combined treatment (seven patients) with oral corticosteroid and itraconazole, itraconazole alone (two patients) or neither oral corticosteroid nor itraconazole therapy (two patients) total serum IgE and specific IgE to rAsp f 4 and/or rAsp f 6 did decrease but did not normalize. Over the observation period, lung function remained unchanged, independent of whether oral steroids and/or concomitant itraconazole were either given or not given. In the follow-up of CF patients with ABPA under therapy the determination of total or specific IgE serum levels were of limited value to guide therapy.

Diagnosis and treatment of allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is an underdiagnosed pulmonary disorder in asthmatic patients and patients with cystic fibrosis. Its clinical and diagnostic manifestations arise from an allergic response to multiple antigens expressed by fungi, most commonly Aspergillus fumigatus, colonizing the bronchial mucus. The clinical course is one of recurrent exacerbations characterized by chest infiltrates evident on chest x-ray films and associated with cough, wheeze, and sputum production that usually respond to oral corticosteroid treatment. Specific immunologic and radiologic markers of disease include elevation of the total serum IgE levels, presence of aspergillus IgE antibodies, and the occurrence of central bronchiectasis. Long-term treatment with corticosteroids is often required for effective management. The adverse effects of chronic corticosteroid use have led to attempts at treatment with antifungal agents such as itraconazole. Itraconazole has been reported anecdotally to be effective, and evidence for its effectiveness in randomized trials is still accruing. Consideration should be given to its use as a corticosteroid-sparing agent or for treatment of patients in whom corticosteroid response is poor. The natural history and prognosis of ABPA are not well characterized but may be complicated by progression to bronchiectasis and pulmonary fibrosis. If ABPA is diagnosed and treated before the development of bronchiectasis and fibrosis, these complications may be prevented.

Immunological characterization of Asp f 2, a major allergen from Aspergillus fumigatus associated with allergic bronchopulmonary aspergillosis

The 37-kDa recombinant protein Asp f 2, encoding an allergen of Aspergillus fumigatus, was expressed in a prokaryotic expression system and immunologically evaluated for its functional and structural properties. The open reading frame for a 310-amino-acid-long protein was shown to encode a signal peptide of 31 amino acids. A native 37-kDa culture filtrate protein and a 55-kDa mycelial glycoprotein (gp55) exhibited complete N-terminal sequence homology to Asp f 2. A GenBank search for homologous proteins revealed 60 and 44% sequence homologies to the cytosolic protein ASPND1 from Aspergillus nidulans and fibrinogen binding protein from Candida albicans, respectively. The glycosylation sites and cysteine molecules are conserved in all the three proteins. The extracellular matrix protein laminin showed a dose-dependent interaction with Asp f 2. This protein, expressed as a major cell-associated protein within 24 h of in vitro fungal culture, comprises 20 to 40% of total fungal protein. Furthermore, both native and recombinant Asp f 2 exhibited specific immunoglobulin (IgE) binding with allergic bronchopulmonary aspergillosis (ABPA) and cystic fibrosis-ABPA patients, whereas A. fumigatus-sensitized allergic asthma and normal control subjects failed to show IgE binding with Asp f 2. These results indicate that Asp f 2 is a major allergen of A. fumigatus exhibiting IgE antibody binding with sera from patients with ABPA. The antigen should be explored further for its potential role in the differential diagnosis of A. fumigatus-associated allergic diseases.

Bronchiectasis

Imaging has a key role in the identification of bronchiectasis. Over the years, imaging tests have become increasingly accurate in depicting the features of early bronchiectasis. This article covers the clinical, pathologic, and functional features of bronchiectasis; high-resolution CT scan technique; the signs of bronchiectasis on chest radiography and high-resolution CT scan; and the causes of misdiagnosis of bronchiectasis.

Molecular cloning and expression of a recombinant Aspergillus fumigatus protein Asp f II with significant immunoglobulin E reactivity in allergic bronchopulmonary aspergillosis

The cDNA of Aspergillus fumigatus encoding an allergen was cloned and expressed in Escherichia coli. The 987 bp long cDNA clone expressed a recombinant protein Asp f II of 34 kd. This protein exhibited binding to immunoglobulin E (IgE) in the serum samples from patients with allergic bronchopulmonary aspergillosis (ABPA). The patients with ABPA and central bronchiectasis demonstrated high levels of serum IgE antibodies, whereas patients with ABPA without central bronchiectasis, patients with asthma and Aspergillus skin test reactivity but no evidence of ABPA, and patients with aspergilloma showed only low levels of IgE antibody to Asp f II. In two-dimensional electrophoresis, a native antigen electroeluted from an A. fumigatus culture filtrate antigen preparation showed an isoelectric point and molecular weight similar to that of Asp f II. In a competitive enzyme-linked immunosorbent assay (ELISA), the IgE antibody reactivity of Asp f II with patient serum samples could be significantly inhibited by culture filtrate antigens of A. fumigatus. These results indicate that Asp f II has immunologic reactivities comparable to those of native A. fumigatus antigens. The recombinant Asp f II can be expressed in E. coli in large quantities and should prove useful as a standardized allergen for sensitive and specific immunodiagnosis of ABPA, especially in patients with central bronchiectasis.

Accuracy of CT in predicting the cause of bronchiectasis

There are many reports that state that the distribution and pattern of bronchiectasis may be sufficiently characteristic for a specific cause to be suggested. The aim of this study was to determine whether experienced chest radiologists could confidently and accurately diagnose various aetiologies of bronchiectasis from the computed tomography (CT) pattern of disease alone. CT scans of 108 patients with bronchiectasis of various causes (67 with idiopathic bronchiectasis, 10 with allergic bronchopulmonary aspergillosis, 12 with syndromes of impaired mucociliary clearance, 12 with hypogammaglobulinaemia and seven with adult cystic fibrosis) were assessed by three chest radiologists without knowledge of clinical data. Each observer listed the three most likely diagnoses in order of probability. In addition, a level of confidence on a 3-point scale was assigned to the first choice diagnosis. A correct first-choice diagnosis was made in 45% of readings. A high confidence level was given in only 9% of the first choice readings. Of these, a correct diagnosis was reached in 35%. There was poor interobserver agreement (mean kappa = 0.20). In conclusion, we found that the causes of bronchiectasis cannot be reliably diagnosed on the basis of CT appearances alone.

Rise in total IgE as an indicator of allergic bronchopulmonary aspergillosis in cystic fibrosis

BACKGROUND

Allergic bronchopulmonary aspergillosis is a serious complication of cystic fibrosis and may be difficult to diagnose. The aim of this study was to define the usefulness of measuring total IgE compared with other major criteria in the diagnosis of allergic bronchopulmonary aspergillosis in children with cystic fibrosis.

METHODS

A retrospective analysis was carried out of the case records of 160 children attending a tertiary referral paediatric cystic fibrosis clinic.

RESULTS

Sixteen children had a total IgE level above 500 IU/ml. Eleven children had six or more other major criteria and were considered to have allergic bronchopulmonary aspergillosis. These 11 children had a fourfold rise in IgE in association with clinical deterioration. A further child had a fourfold rise in IgE to 341 IU/l, and was also thought to have allergic bronchopulmonary aspergillosis. Eleven had a fall in IgE with successful treatment; one patient died with uncontrolled disease. Only one of these 12 children had negative precipitins to Aspergillus fumigatus. The five children with a raised IgE not thought to have bronchopulmonary aspergillosis had four or fewer major criteria and were not treated; none had positive precipitins.

CONCLUSIONS

A fourfold rise in total IgE, particularly to above 500 IU/ml, is strongly suggestive of the diagnosis of allergic bronchopulmonary aspergillosis in children with cystic fibrosis. The measurement of total IgE has the merit of being simple to perform and objective. Positive aspergillus precipitins provide useful confirmatory evidence. These two criteria, taken in conjunction with clinical deterioration and new radiological shadowing, allow simplification of the diagnosis of allergic bronchopulmonary aspergillosis in cystic fibrosis.

The approach to nonresolving pneumonia

Pneumonias that fail to resolve at the expected rate may reflect derangements in host defenses, inadequate or inappropriate antimicrobial therapy, highly virulent pathogens, or myriad noninfectious causes. In this article, noninfectious causes of pulmonary infiltrates mimicking community-acquired pneumonia are discussed. The salient clinical, radiographic, and histopathologic features of diverse immune-mediated syndromes are reviewed, and an approach to diagnosis and therapy of nonresolving pneumonias is presented.

Particulate Aspergillus fumigatus antigens elicit a TH2 response in BALB/c mice

BACKGROUND

In order to understand the immunoregulation in allergic aspergillosis, a murine model was developed by exposing animals to particulate and soluble antigens of Aspergillus fumigatus.

METHODS

BALB/c mice were exposed to soluble Aspergillus antigen intranasally. Animals showing moderate levels of IgE were subsequently exposed to soluble antigen or antigen conjugated to polystyrene beads intranasally. The IgE and IgG1 in the sera and the eosinophils in the blood and lungs were studied. The spleen and lung mononuclear cells were stimulated with both concanavalin A and antigen and evaluated for production of interleukin (IL)-4, IL-5, IL-10, and interferon-gamma.

RESULTS

Animals exposed to particulate antigens showed more elevated serum IgE levels and increased numbers of eosinophils in the blood and lungs than those exposed to soluble antigen. Lung cell cultures from animals exposed to particulate antigens when stimulated with Aspergillus produced IL-4 and IL-5, indicating a TH2 type of response. Animals exposed to soluble antigens showed a weaker TH2 response, as evidence by low IgE levels in sera, fewer eosinophils in the blood, and low levels of cytokine production from lung and spleen cells.

CONCLUSION

The results indicate that the physical nature of the antigen may have a major role in determining the type of immune response of the host.

Complicating features of asthma

The recognition of factors other than asthma that make asthma worse, are confused with asthma, or occur concurrently with asthma and may or may not interact with asthma is as important as dealing with the asthma itself. In this article I have tried to give an overview of some of these factors: what they are, how they affect patients with asthma, and what to do about them. The recognition of a covert chronic sinusitis, for example, is often key to controlling a person's disease when it appears that everything is being done appropriately. Close attention to these factors will increase the success of treatment of asthma and improve the quality of life of patients.

Fibrotic stage of allergic bronchopulmonary candidiasis

Since its first description in 1952, ABPA has been recognized with increasing frequency. More recently fungi other than Aspergillus fumigatus, in particular Candida albicans, have been implicated in a similar disease process. The following case report illustrates the possibility of finding a fibrotic stage 5 ABPM caused by C albicans.

Plastic bronchitis: an old disease revisited

Expectoration of bronchial casts (plastic bronchitis) is an uncommon but ancient problem. Herein we describe a 40-year-old man, with no prior lung disease, who had dyspnea, cough, and expectoration of long branching bronchial casts. No specific cause was delineated, although special stains for eosinophilic granule major basic protein demonstrated occasional foci of eosinophils and small amounts of extracellular major basic protein in the bronchial casts. Various diseases, such as allergic bronchopulmonary aspergillosis, bronchiectasis, and cystic fibrosis, have been associated with the formation of bronchial casts and should be considered in the differential diagnosis. Although most previously reported cases have been associated with some type of pulmonary disease, our patient had no evidence of an underlying pulmonary disorder.