In view of the good response to bronchodilators and history of gastrointestinal complications, steroid therapy was not initiated. She was discharged from the hospital after seven days on a regimen of oral theophylline, penicillin, and an inhaled bronchodilator. Six weeks following hospital discharge, a repeated chest roentgenogram revealed disappearance of the chest roentgenograph it densities (Fig 2b). Cultures for fungi and mycobacteria were negative, and subsequent testing revealed a sweat chloride of 28 mEq/L by pilocarpine iontophoresis, absence of immediate and delayed Aspergillus skin sensitivity, and normal bronchial size by computed tomography of the chest. Pulmonary function tests showed mild obstructive ventilatory impairment.
The syndrome of mucoid impaction of the bronchi associated with asthma or chronic bronchitis was first described in ten patients by Shaw in 1951. In a review of findings in 85 patients (including Shaw’s ten cases), Urschel et al found that asthma and a productive cough were present in most, and fever, chest pain, expectoration of plugs, and hemoptysis were less commonly associated. In addition to asthma and bronchitis, bronchial atresia, adenoma, carcinoma, tuberculosis, and bronchocentric granulomatosis have been described as resulting in mucoid impaction.’
Hinson et al first described the association of asthma with a hypersensitivity reaction to Aspergillus fumigatus, now referred to as allergic bronchopulmonary aspergillosis (ABPA). Large areas of consolidation lasting one to six weeks were described, as well as transient lobar collapse. The hallmark of the lung abnormality was proximal bronchiectasis associated with mucous plugs that could be recurrent. The diagnosis of ABPA is further supported by skin test reactivity to Aspergillus antigens as well as evidence of eosinophilia, IgG precipitins to Aspergillus antigens, and increased IgE levels in serum. In the patient described, each of these tests used to support a diagnosis of ABPA was negative and computed tomography of the chest revealed normal bronchial size.