She was transferred to the intensive care unit and was started on intravenous methylprednisolone 60 mg every 6 h because of intense inflammation of the airways and a history of asthma. After four days she was extubated, and methylpred-nisolone was discontinued. Biopsies showed noncaseating granulomas without evidence of mycobacterial or fungal infection on tissue stains or bronchial wash stains and cultures. Results of fungal and connective tissue disease serologies were negative. A tuberculin skin test was nonreactive. She denied exposure to known causes of hypersensitivity pneumonitis, and did not travel to areas endemic for dimorphic fungi. Spirometry, tests of lung volumes and carbon monoxide diffusing capacity, and a flow volume loop (FVL) were performed one day after extubation. All of these results were normal, including both limbs of the FVL. The patient elected not to start oral glucocorticoids and was discharged home. Due to persistent cough, bronchoscopy was repeated two weeks later and showed a significant decrease in airway narrowing (Figure 1D). The left bronchial tree was easily explored, but there was still intense erythema, mainly of the trachea and main stem bronchi. CXR and spirometry with a FVL showed no changes. This time, endobronchial biopsies only showed submucosal inflammation, and cultures were again negative. It was decided to treat the patient with fluticasone 440 |lg twice daily. After four weeks of therapy, her cough resolved. The patient was not followed up further until one year later, when she returned to the outpatient clinic with a persistent, nonproductive cough. She had discontinued fluticasone soon after her symptoms resolved and was not on any other therapy. CXR, spirometry, tests of lung volumes and carbon monoxide diffusing capacity, and a FVL were repeated without new findings. Bronchoscopy was again performed, and this time, it revealed minimal nodularity of the left main stem, right upper lobe and right middle lobe bronchi with mild diffuse erythema. Fluticasone was prescribed as previously, but she has not made any more clinic visits to date.
Category: Masquerading as asthma
Tags: Asthma, Bronchoscopy, Glucocorticoids, Sarcoidosis
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