To the Editor:
Allergic bronchopulmonary aspergillosis (ABPA) is an immunological pulmonary disorder caused by hypersensitivity reactions to fungal antigens released by Aspergillus fumigatus [1]. Several aspects of the disease remain an enigma despite being described six decades ago by Hinson et al. [2]. The clinical presentation is that of poorly controlled asthma, mucus plugging and bronchiectasis [3], and the diagnosis of ABPA is made on a composite of clinico-radiological and immunological findings [4]. The primary management of ABPA involves the use of glucocorticoids as an anti-inflammatory agent. Azoles are used in patients with recurrent exacerbations, and act by decreasing the fungal burden in the airways, thereby preventing exacerbations [5]. The natural history of ABPA is characterised by repeated episodes of exacerbations requiring glucocorticoids for management [6–8]. Herein, we describe two patients in whom the disease activity remained uncontrolled despite treatment with oral corticosteroids and azoles. These patients were managed successfully with intravenous pulses of high-dose methylprednisolone. We also systematically review the literature on the use of high-dose intravenous methylprednisolone in ABPA.
A 48-year-old male with history of bronchial asthma since 20 years of age was diagnosed with ABPA 6 years previously: A. fumigatus specific IgE 102 kUA·L−1; type I skin reaction against Aspergillus antigen; total serum IgE 1208 IU·mL−1; central bronchiectasis; eosinophil count 620 cells·μL−1; and A. fumigatus precipitins positive. During the course of the disease he had multiple exacerbations, which responded to oral steroids. The patient was also started on itraconazole 200 mg twice daily (four courses, each of 6 months duration) for recurrent exacerbations. His last exacerbation was 8 months ago. Current therapy included prednisolone 15 mg every other day along with inhaled bronchodilators and …
