Date: 26 November 2013
This recording of peak flow was taken prior to and during the first 4 weeks of inhaled steroids (Becotide 100 and Duovent both 2 puffs 4x daily). The patient had had asthma since age 4, and been treated with bronchodilators and oral courses of steroids when severely affected. The chart, which the patient completed at home, shows that early in week one her peak flow varied from 200-250 L/min. As the medication started to work, the peak flows gradually increased to reach 360-420 L/min in the 4th week. The lower value each morning is characteristic of asthma.
The response to steroids is important confirmation of the diagnosis of asthma (reversible airways obstruction). Many years later she developed ABPA, while on inhaled steroids, with severe upper lobe central bronchiectasis, an IgE of 6,800 Kiu/L, positive aspergillus precipitins, an Aspergillus RAST of 58.7KUa/L (normal <0.4) and eosinophilia.
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Images library
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Bronchoscopic manifestations of Aspergillus tracheobronchitis. (a) Type I. Inflammatory infiltration, mucosa hyperaemia and plaques of pseudomembrane formation in the lumen without obvious airway occlusion. (b) Type II. Deep ulceration of the bronchial wall. (c) Type III. Significant airway occlusion by thick mucous plugs full of Aspergillus without definite deeper tissue invasion. (d) Type IV. Extensive tissue necrosis and pseudomembrane formation in the lumen with airway structures and severe airway occlusion (Wu 2010).
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High resolution CT showing centrilobular nodular opacities and branching linear opacities (tree-in-bud appearance) (Al-Alawi 2007).
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Chest X-ray showing poorly defined bilateral nodular opacities (Al-Alawi 2007).
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Gross pathologic specimen from autopsy shows the bronchial lumen covered by multiple whitish endobronchial nodules (arrows) (Franquet 2002).
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Invasive tracheobronchitis showing numerous nodules seen during bronchoscopy (Ronan D’Driscoll).
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Pseudomembranous seen overlying the bronchial mucosa (Tasci 2006).