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Correspondence: Address to Adam Austin, MD, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, 2000 SW Archer Road, PO Box 100383, University of Florida, Gainesville, FL 32610-0383, USA.
A middle-aged woman presented with 2 months of productive cough, chest pain, and intermittent hemoptysis. Her medical history was significant for difficult-to-treat asthma and recurrent respiratory infections, including a recent episode of bacterial pneumonia secondary to Pseudomonas aeruginosa. The patient’s physical examination revealed diffuse expiratory wheezes on auscultation throughout all lung fields. Computed tomography of the chest revealed bilateral cystic bronchiectasis and pronounced mucus impaction of the proximal bronchus and distal airways of the left upper lobe (Figure 1).
Figure 1A, High attenuation mucus impaction of left upper lobe bronchus with central prominence and mean 105 Hounsfield units on computed tomography chest scan (axial view). B, Improved finger-in-glove sign after limited trial of biologic therapy for allergic bronchopulmonary aspergillosis, showing residual left upper lobe bronchiectasis.
Her peripheral eosinophil count was elevated at 920,000 cells per cubic millimeter. Her total immunoglobulin E (IgE) was elevated at 4517 kU/L with Aspergillus fumigatus–specific IgE measuring 27.80 kU/L. A serologic workup for bronchiectasis was unrevealing with normal alpha-1 antitrypsin level of 203 mg/dL, and sweat chloride of 20 mEq/L. The patient underwent fiberoptic bronchoscopy with bronchoalveolar lavage revealing 44% eosinophils with normal microbiological workup and cytology. The patient also had a requisite predisposing condition of asthma and idiopathic bronchiectasis as well as imaging consistent with ABPA. Additionally, she had detectable serum-specific IgE against Aspergillus fumigatus (>0.35 kU/L), elevated total serum IgE, and peripheral eosinophilia.
High attenuation mucus (HAM) plugging is consistent with the “finger-in-glove” sign that is pathognomonic for ABPA. Mucus impaction of ABPA is typically hypodense. However, in approximately 20% of cases, there is impaction of hyperdense attenuated mucus that is comparable to the Hounsfield units of the paraspinal and thoracic cage musculature.
High attenuation mucus impaction is caused by an amalgam of mucoid calcium deposition within the airways and is correlated with both disease severity and recurrence.
Finger-in-glove is also referred to as “gloved finger shadows,” which can be identified on both chest radiograph as well as computed tomography imaging in our patient (Figure 2).
The differential diagnosis of HAM impaction includes endobronchial lesions, aspiration of foreign material, broncholithiasis, and non-obstructive mucus plugging in a dilated airway.
Figure 2A, The tubular appearance of high attenuation mucus impaction showing “gloved finger shadows” in the left upper lobe on portable chest radiograph. B-C, The hyperdense Y-shaped mucus plugging of the left upper lobe airway correlating with the chest x-ray appearance (B, coronal view) and (C, sagittal view).
After the diagnosis of ABPA was established, she was prescribed oral itraconazole and corticosteroids, but these were not tolerated due to reported abdominal discomfort. She was nonadherent to airway clearance with inhaled corticosteroids, bronchodilators, and hypertonic saline nebulization. Because of recurrent active disease, the patient was briefly treated with omalizumab, a recombinant humanized IgG1 monoclonal antibody with affinity for circulating IgE. The patient could not tolerate the medication due to self-reported constellation of symptoms, including agitation, tinnitus, and headaches. Although she only tolerated several doses, there was improvement in dyspnea and reportedly no further relapse of disease 1 year after initial administration. Repeat chest imaging has shown resolution of left upper lobe mucus impaction despite a limited trial of biologic therapy (Figure 1).
Potential Competing Interests
The authors report no potential competing interests.
References
Agarwal R.
Chakrabarti A.
Shah A.
et al.
Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria.
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