Naresh Panchal

Concomitant allergic bronchopulmonary aspergillosis and allergic Aspergillus sinusitis: a review of an uncommon association*

Background Although thought to have common immunopathological processes, concomitant occurrence of allergic bronchopulmonary aspergillosis (ABPA) and allergic Aspergillus sinusitis (AAS) appears to be rarely reported as to date only five detailed case reports are available.

Allergic bronchopulmonary aspergillosis: the spectrum of computed tomography appearances.

Although computed tomography (CT) of the thorax has been compared to plain chest radiography and bronchography for demonstration of central bronchiectasis (CB) in allergic bronchopulmonary aspergillosis (ABPA), the CT presentation of the disease is yet to be highlighted. With this in view, the CT appearances in 23 patients with ABPA were evaluated. The scans were assessed for bronchial, parenchymal and pleural abnormalities. Central bronchiectasis was identified in all patients, involving 114 (85%) of the 134 lobes and 210 (52%) of the 406 segments studied. Other bronchial abnormalities such as dilated and totally occluded bronchi (11 patients), air-fluid levels within dilated bronchi (five patients), bronchial wall thickening (10 patients) and parallel-line shadows (seven patients) were also observed. Parenchymal abnormalities, which had a predilection for upper lobes, included consolidation in 10 (43%) patients, collapse in four (17%) patients and parenchymal scarring in 19 (83%) patients. A total of six cavities were seen in three (13%) patients, and an emphysematous bullae was detected in one (4%) patient. The pleura was involved in 10 (43%) patients. Ipsilateral pleural effusion with collapse was observed in one patient, while in nine other patients, parenchymal, lesions extended up to the pleura. Concomitant allergic Aspergillus sinusitis (AAS) was also detected in three (13%) of the 23 patients. Computed tomography of the thorax in patients with ABPA provides a sensitive method for the assessment of bronchial, parenchymal and pleural abnormalities, and should constitute a part of the diagnostic work of the disease.

Central bronchiectasis in allergic bronchopulmonary aspergillosis: comparative evaluation of computed tomography of the thorax with bronchography

Demonstration of central bronchiectasis (CB) with normal peripheral bronchi is an essential requirement for the diagnosis of allergic bronchopulmonary aspergillosis (ABPA). Although the results of bronchography remain the gold standard for demonstration of central bronchiectasis they are not always diagnostic. Moreover, it is an unpleasant invasive procedure which may be difficult to perform in a patient of allergic bronchopulmonary aspergillosis with acute severe asthma. In an attempt to find a safe and effective alternative to demonstrate central bronchiectasis computed tomography (CT) of the thorax was evaluated against bronchography. Twenty one patients with allergic bronchopulmonary aspergillosis underwent computed tomography of the thorax followed by bronchography. Of the 378 bronchopulmonary segments available for analysis, 42 had to be excluded because of consolidation or non-filling of the contrast dye, leaving 336 segments for evaluation. CB was identified on CT in all 21 patients. Detailed analysis of the visualized segments revealed that computed tomography (using 8 mm contiguous scans) identified 146 of the 212 segments showing central bronchiectasis on bronchography (sensitivity 70%) and 114 of the 124, read as normal on bronchography (specificity 92%). Supplemental 4 mm scans, used in 8 out of 21 patients improved the overall sensitivity of computed tomography to 83%, whilst the specificity remained unchanged at 92%. Thus, computed tomography of the thorax, being more acceptable to the patient, has the potential of being the investigation of choice for the demonstration of central bronchiectasis in patients with allergic bronchopulmonary aspergillosis.

CT in childhood allergic bronchopulmonary aspergillosis

CT of the thorax done during acute severe asthma in two paediatric patients demonstrated central bronchiectasis, a sine qua non for the diagnosis of allergic bronchopulmonary aspergillosis. Bronchography, regarded as the gold standard, was done subsequently on recovery. A comparative segmental analysis revealed that CT was able to identify immediately 24 of 27 segments which showed central bronchiectasis on bronchography. Early diagnosis with the aid of CT enabled immediate intervention which may have helped to prevent further lung damage in the paediatric patients.

Chronic anaerobic pneumonitis in a seven‐year‐old girl

A 7‐year‐old girl was referred for evaluation of chronic pulmonary disease associated with nasal symptoms of 4 years duration for which she had received frequent courses of antibiotics. Serial chest roentgenograms over a period of 2 years revealed a nonhomogeneous opacity in the right lower lung zone for which she had received 18 months of antituberculous therapy without relief. Evaluation of the patient led to the diagnosis of chronic anaerobic pneumonitis, a rare clinical entity in children. In addition, the patient also had bronchial asthma and chronic rhinitis. Therapy with oral phenoxymethylpenicillin and metronidazole for 6 weeks along with appropriate antiasthma medications abolished her symptoms and resulted in roentgenologic clearance. Pediatr Pulmonol. 1998; 26:135–137.

Response by Authors

To the Editor: Molsberger et al. claim that ‘‘Chinese acupuncture is an effective alternative to conventional orthopaedic treatment of chronic shoulder pain’’ [1]. After studying their report carefully, I still wonder whether the outcomes they noted are due to specific or nonspecific effects. Even though these authors affirm that ‘‘patients were blinded to whether they received verum or sham acupuncture,’’ they fail to report the success of their attempts to blind patients. Considering that verum consisted of 8 needles mostly in the area of pain, and sham of 4 needles over the tibia, I very much doubt that patients were truly blind. Moreover, we know that the communication style of the clinician significantly determines the success of acupuncture [2]. A devil’s advocate might suspect that the doctors administering the treatment had an interest in generating a positive result, which might lead to the German health insurance companies reimbursing them for using acupuncture. I do wonder to what extent these factors influenced the results of that study.