Successful control of exacerbation of Allergic Bronchopulmonary Aspergillosis due to Aspergillus terreus in a cystic fibrosis patient with short-term adjunctive therapy with voriconazole: A case report

Abstract

A 12-year-old boy with cystic fibrosis (CF) and a history of glucocorticoid-dependent allergic bronchopulmonary aspergillosis (ABPA) was referred to our hospital. The ABPA was diagnosed when he was 8 years old and he had been treated with several course of oral glucocorticoids for recurrent exacerbations. He was readmitted when aged 12 with a history of worsening shortness of breath and chest tightness. A recurrence of ABPA was diagnosed based on eosinophilia and elevation of Aspergillusspecific IgE and IgG, and total IgE. Thoracic high-resolution computed tomography (HRCT) showed central bronchiectasis with parenchymal infiltrates. The treatment started with itraconazole and oral corticosteroid. After 2 months of treatment, he was re-admitted to the hospital due to a progressive worsening of respiratory symptoms. Chest HRCT revealed the a sub segmental atelectasis in the left lung. Microscopic examination of sputum and BAL samples demonstrated septate hyphae consistent with Aspergillus species. Sputum and BAL culture yielded Aspergillus ochraceus and Aspergillus terreus, which were both sensitive to itraconazole and voriconazole. The treatment was switched to voriconazole and the patient showed significant clinical, serological and mycological improvement after three months. This case shows that voriconazole may be used as an alternative for treatment of ABPA due to Aspergillus terreus.

Introduction

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity lung disorder characterized by airway inflammation, elevated levels of Aspergillus specific IgE and IgG, elevated total IgE and positive skin sensitivity to Aspergillusallergens/proteins [1], [2]. Aspergillus fumigatus was reported as the most common etiologic agent of ABPA, however other species of Aspergillusare rarely implicated [3]. ABPA typically occurs in patients with asthma or cystic fibrosis (CF) with a 2–15% rate in CF patients [4], [5]. The global burden of ABPA in CF patients is estimated at about 7000 cases annually [6]. Glucocorticoids are the mainstay of management of ABPA; however, the use of antifungals (usually itraconazole) in patients with slow or poor response to steroids, frequent relapses, steroid-dependent ABPA, or steroid toxicity has been recommended by a consensus expert panel [5].

Here, we report an unusual case of ABPA exacerbation due to two different non-fumigatus Aspergillus species that was successfully controlled by short-term course of voriconazole therapy after a failed itraconazole treatment.