Allergic bronchopulmonary aspergillosis with hilar adenopathy in a 42-Month-old boy
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Pediatric Pulmonology 42:747–748 (2007) Allergic Bronchopulmonary Aspergillosis With Hilar Adenopathy in a 42-Month-Old Boy To the Editor, Allergic bronchopulmonary aspergillosis (ABPA) is reported to occur in 7.6% of Indian adults with asthma 1 but, is rarely reported in children without cystic fibrosis, especially in those less than 10 years of age. The rarity of such a report prompted this description of a 42-month-old boy with ABPA and hilar lymphadenopathy. The child, referred for evaluation of radiological infiltrates, had wheezing dyspnoea and cough for the past 1 year. His mother, maternal grandmother and paternal grandfather were all asthmatics. Six months prior to referral, he had received, for the radiological infiltrates, antituberculous therapy without relief. A review of serial chest roentgenograms over the past 1 year revealed transient pulmonary infiltrates. CT of the thorax, done on presentation, showed pretracheal and right hilar lymphadenopathy (Fig. 1a) with central bronchiectasis in right lower and left upper lobes (Fig. 1b). Mucoid impaction was also seen in the right upper lobe. On auscultation, polyphonic rhonchi and coarse crepitations were audible. The total blood count was 9,700/mm 3 with 10% eosinophils with an absolute count of 900/mm 3 . The child could not perform spirometry. Intradermal challenge with extracts of Aspergillus fumigatus and flavus gave strong type I and type III reactions. Gel diffusion studies showed strong bands of serum precip- itans against A. fumigatus. The total IgE was raised to 1,651 IU/ml. The specific IgE and IgG against A. fumigatus were positive. A diagnosis of ABPA with mediastinal lymphadenopathy was made. The patient had a remarkable symptomatic response to oral prednisolone 10 mg daily (0.5 mg/kg) which was reduced to alternate day after 2 weeks and tapered. There was significant radiological clearing after 1 month. The diagnosis of ABPA in children less than 5 years of age is rarely thought of, especially, in the absence of cystic fibrosis. ABPA was reported in infants as young as 6 months. 2 Although ABPA is well known to complicate children with cystic fibrosis, our patient had no clinical evidence to suggest this entity which is a rarity in our country. Early diagnosis is vital to prevent irreversible fibrotic changes. We have reported an 11-year-old boy with ABPA who had cavitation and clubbing. 3 The first roentgenologic lesion in our patient was detected at two and a half years of age. Within 1 year we demonstrated extensive central bronchiectasis. CT—thorax helps to safely and rapidly demonstrate central bronchiectasis which remains a sine qua non for the diagnosis of ABPA. 4,5 In addition, CT helped us to demonstrate hilar lymphadenopathy, which has been documented in ABPA. However, this feature is yet to receive recognition and is reported to regress with steroid therapy. 6 Suspicion of ABPA in such a clinical setting even with the presence of lymphadenopathy can avoid invasive procedures. To our knowledge, this is the first report of hilar lymphadenop- athy in ABPA in the pediatric age group. Fig. 1. (a) Contrast enhanced computed tomography of thorax (mediastinal window) showing right hilar lymphadenopathy. (b) Contrast enhanced computed tomography thorax (lung window) showing central bronchiectasis in the left upper lobe. *Correspondence to: Ashok Shah, Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, P.O. Box 2101, Delhi 110 007, India. E-mail: [email protected] DOI 10.1002/ppul.20639 Published online 27 June 2007 in Wiley InterScience (www.interscience.wiley.com). ß 2007 Wiley-Liss, Inc.
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Transcript of Allergic bronchopulmonary aspergillosis with hilar adenopathy in a 42-Month-old boy
Pediatric Pulmonology 42:747–748 (2007)
Allergic Bronchopulmonary Aspergillosis WithHilar Adenopathy in a 42-Month-Old Boy
To the Editor,
Allergic bronchopulmonary aspergillosis (ABPA) isreported to occur in 7.6% of Indian adults with asthma1
but, is rarely reported in children without cystic fibrosis,especially in those less than 10 years of age. The rarity ofsuch a report prompted this description of a 42-month-oldboy with ABPA and hilar lymphadenopathy.
The child, referred for evaluation of radiologicalinfiltrates, had wheezing dyspnoea and cough for the past1 year. His mother, maternal grandmother and paternalgrandfather were all asthmatics. Six months prior toreferral, he had received, for the radiological infiltrates,antituberculous therapy without relief. A review of serialchest roentgenograms over the past 1 year revealedtransient pulmonary infiltrates. CT of the thorax, doneon presentation, showed pretracheal and right hilarlymphadenopathy (Fig. 1a) with central bronchiectasisin right lower and left upper lobes (Fig. 1b). Mucoidimpaction was also seen in the right upper lobe. Onauscultation, polyphonic rhonchi and coarse crepitationswere audible. The total blood count was 9,700/mm3
with 10% eosinophils with an absolute count of 900/mm3.
The child could not perform spirometry. Intradermalchallenge with extracts of Aspergillus fumigatus andflavus gave strong type I and type III reactions. Geldiffusion studies showed strong bands of serum precip-itans against A. fumigatus. The total IgE was raised to1,651 IU/ml. The specific IgE and IgG against A.fumigatus were positive. A diagnosis of ABPA withmediastinal lymphadenopathy was made. The patient hada remarkable symptomatic response to oral prednisolone
10 mg daily (0.5 mg/kg) which was reduced to alternateday after 2 weeks and tapered. There was significantradiological clearing after 1 month.The diagnosis of ABPA in children less than 5 years of
age is rarely thought of, especially, in the absence of cysticfibrosis. ABPA was reported in infants as young as6 months.2 Although ABPA is well known to complicatechildren with cystic fibrosis, our patient had no clinicalevidence to suggest this entity which is a rarity in ourcountry. Early diagnosis is vital to prevent irreversiblefibrotic changes. We have reported an 11-year-old boywith ABPA who had cavitation and clubbing.3 The firstroentgenologic lesion in our patient was detected at twoand a half years of age. Within 1 year we demonstratedextensive central bronchiectasis. CT—thorax helps tosafely and rapidly demonstrate central bronchiectasiswhich remains a sine qua non for the diagnosis ofABPA.4,5 In addition, CT helped us to demonstrate hilarlymphadenopathy, which has been documented in ABPA.However, this feature is yet to receive recognition and isreported to regress with steroid therapy.6 Suspicion ofABPA in such a clinical setting even with the presence oflymphadenopathy can avoid invasive procedures. To ourknowledge, this is the first report of hilar lymphadenop-athy in ABPA in the pediatric age group.
Fig. 1. (a) Contrast enhanced computed tomography of thorax (mediastinal window) showing
right hilar lymphadenopathy. (b) Contrast enhancedcomputed tomography thorax (lungwindow)
showing central bronchiectasis in the left upper lobe.
*Correspondence to: Ashok Shah, Department of Respiratory Medicine,
Vallabhbhai Patel Chest Institute, University of Delhi, P.O. Box 2101, Delhi
110 007, India. E-mail: [email protected]
DOI 10.1002/ppul.20639
Published online 27 June 2007 in Wiley InterScience
(www.interscience.wiley.com).
� 2007 Wiley-Liss, Inc.
—ASHOK SHAH, MD*JAYA KALA, MBBS
SANDEEP SAHAY, MBBS
Department of Respiratory MedicineVallabhbhai Patel Chest Institute
University of Delhi, P.O. Box 2101Delhi 110 007, India
REFERENCES
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to Aspergillus antigen and occurrence of allergic bronchopulmo-
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2. Imbeau SA, Cohen M, Reed CE. Allergic bronchopulmonary
aspergillosis in infants. Am J Dis Child 1977;131:1127–1130.
3. Shah A, Bhagat R, Panchal N. Allergic bronchopulmonary
aspergillosis with clubbing and cavitation. Indian Paediatr 1993;
30:248–251.
4. Shah A, Pant CS, Bhagat R, Panchal N. CT in childhood allergic
bronchopulmonary aspergillosis. Pediatr Radiol 1992;22:227–228.
5. Shah A, Panjabi C. Allergic bronchopulmonary aspergillosis: A
review of a disease with a world wide distribution. J Asthma 2002;
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6. Shah A, Agarwal AK, Chugh IM. Hilar adenopathy in allergic
bronchopulmonary aspergillosis. Ann Allergy Asthma Immunol
1999;82:504–506.
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