Atypical Presentation of Allergic Bronchopulmonary Aspergillosis: An Unusual Cause of Difficult-to-Treat Asthma

Allergic Bronchopulmonary aspergillosis (ABPA) commonly presents with persistently uncontrolled asthma, despite of the therapy with highest possible anti–asthma medications. Most common cause of ABPA is Aspergillus fumigates. Hence, ABPA is one of the important differential diagnoses of difficult-to-treat asthma. Atypical presentation of ABPA misleads the diagnosis and asthma remains uncontrolled. Here we present such a case of 28-year-old non–smoker, normotensive male office worker who presented with persistent cough with scanty white, mucoid expectoration and gradually progressive breathlessness with bilateral crackles for last two years. Diagnosis of asthma was made based on clinical evidences and spirometry. Anti–asthma treatment was started and gradually stepped up. Further evaluation was done due to lack of clinical improvement, and diagnosis of ABPA was made from bilateral reticulonodular lesions on HRCT thorax, increased levels of serum IgE and Aspergillus fumigates specific IgE, and positive aspergillin skin test. Oral prednisolone and itraconazole were started with anti–asthma medications.