564 Is It Really Difficult-to-treat Asthma? Don't Forget Other Causes of Wheeze

BACKGROUND: One in 4 asthma patients may not have their condition adequately controlled and experience persistent symptoms despite treated with high healthcare utilization. But do all of them really have asthma? METHODS: Here we present 3 cases; all were diagnosed as asthma, had been treating with multiple bronchodilators, even oral steroids and were not responding to the treatment. And so they were refered to our clinic as having difficult-to-treat asthma as candidates for omelizumab therapy. RESULTS: Case1: A 44-year-old female presented with 18 years history of dyspnea, wheeze and chronic cough. Her FEV1 was 37% of the predicted (0.93 lt), FVC and FEV1/FVC were subnormal and showed no reversibility. CT scan showed a deformed trachea with a diverticula in the posterior region with cystic bronchiectasis in lung parenchyma, bilaterally. Bronchial endoscopy showed dyskinesia extending almost totally throughout the tracheobronchial tree with complete expiratory collapse. Her diagnosis was changed as Mounier-Kuhn syndrome. Case 2: A 19-year-old female presented with 11 years history of persistent wheezing and dyspnea which were progressively increasing for the last 5 years. Her FEV1 was 85% and the FEV1/FVC % 77 of the predicted, showed no reversibility. Her CT scan was in normal limits. Fiberoptic bronchoscopy revealed a severe airway stenosis like a pinhole at the beginning of the right main bronchus, adjacent to the carina. Excluding her asthma diagnosis she underwent a balloon dilatation procedure, which improved her symptoms. Case 3: A 50-year-old female presented with 16 years history of dyspnea, wheeze, chronic cough. Her FEV1 was 40% of the predicted (0.91 lt), and showed reversibility of 28%. She had an elevated total IgE level of 1126 IU/mL with serum eosinophilia of 5.5%. Her HRCT scan revealed bilateral central bronchiectasis with fleeting pulmonary parenchymal opacities. Her sensitization to Aspergillus fumigatus was shown by positive skin testing. She was diagnosed as having allergic bronchopulmonary aspergillosis and oral itracanosole with steroid were added to her treatment which improved her symptoms. CONCLUSIONS: Although all patients' symptoms looked like asthma, and all diagnosed as having asthma for many years, the diagnosis should always be confirmed before accepting them as “difficult-to-treat”.