Cases reported • Asthma; Asthma, Bronchial; Bronchial Asthma

11/145. Severe allergic bronchopulmonary aspergillosis in an infant with cystic fibrosis and her asthmatic father.

An infant with cystic fibrosis and her asthmatic father were diagnosed as suffering from allergic bronchopulmonary aspergillosis (ABPA). cystic fibrosis was diagnosed in the infant at 6 weeks of age, and gene mutations were W1282X/G542X. She was diagnosed definitively as suffering from ABPA at age 3.5 years, but had suggestive symptoms from age 11 months. This may be the youngest age described to date for ABPA. The child responded well to systemic steroid therapy, but remained steroid-dependent over the next 4 years. Treatment with itraconazole enabled a marked reduction in steroid dosage. The father was an asthmatic, and a heterozygote for the cystic fibrosis transmembrane regulator (CFTR) mutation W1282X. He had a normal sweat test, atopy, and moderate reversible airway obstruction. There was no proven exposure to aspergillus in the home environment. The importance of considering the diagnosis of ABPA even in infancy, the therapeutic dilemmas, and the possible role of abnormal CFTR function in the development of ABPA are discussed.

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12/145. churg-strauss syndrome in patients receiving montelukast as treatment for asthma.

STUDY OBJECTIVES: We previously reported eight patients who developed churg-strauss syndrome in association with zafirlukast treatment for asthma and postulated that the syndrome resulted from unmasking of a previously existing condition due to corticosteroid withdrawal and not from a direct drug effect. The availability of montelukast, a new leukotriene receptor antagonist with a different molecular structure, permitted us to test this hypothesis. Our goals were to ascertain whether the churg-strauss syndrome developed in patients taking montelukast and other novel asthma medications, and to describe potential mechanisms for the syndrome. DESIGN: Case series. SETTING: Outpatient and hospital practices of pulmonologists in the united states and belgium. patients: Four adults (one man, three women) who received montelukast as treatment for asthma; two women who received salmeterol/fluticasone therapy, but not montelukast. RESULTS: churg-strauss syndrome developed in the four asthmatic patients who received montelukast. In each case, there was a long history of difficult-to-control asthma characterized by multiple exacerbations that had required frequent courses of oral systemic corticosteroids or high doses of inhaled corticosteroids for control. Two other asthmatics who received fluticasone and salmeterol but not montelukast therapy developed the same syndrome with tapering doses of oral or high doses of inhaled corticosteroids. CONCLUSIONS: The occurrence of churg-strauss syndrome in asthmatic patients receiving leukotriene modifiers appears to be related to unmasking of an underlying vasculitic syndrome that is initially clinically recognized as moderate to severe asthma and treated with corticosteroids. Montelukast does not appear to directly cause the syndrome in these patients.

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13/145. hyperthyroidism complicating asthma treatment.

asthma is one of the most common chronic medical conditions. The usual treatment includes quick relief bronchodilator medications of the sympathomimetic class and controller medications that may include the long-acting inhaled bronchodilator salmeterol. Mild adverse cardiac and central nervous system effects are common with these medications, requiring modifications in dose or occasionally switching to a different medication. Both asthma and thyroid disease are common disorders that occasionally occur together. hyperthyroidism may exacerbate asthma. Many symptoms of hyperthyroidism are identical to the adverse effects of the commonly used inhaled bronchodilators and include tremor, nervousness, tachycardia, wide pulse pressure, palpitations, emotional lability, agitation, nightmares, aggressive behavior, and diarrhea. In this report we describe a patient with hyperthyroidism whose symptoms initially were thought to be adverse effects of the inhaled bronchodilator medications.

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14/145. A family with extrinsic allergic alveolitis caused by wild city pigeons: A case report.

We describe a family in which the mother died of unresolved lung disease and whose 5 children, some of whom had previous signs of asthma, were subsequently affected by extrinsic allergic alveolitis caused by contact with wild city pigeon antigens. The children received systemic corticosteroids for 1 month and inhaled steroids for 24 months, while antigen exposure was reduced as much as feasible. This was followed by a quick clinical recovery and a slow normalization of chest radiographs and pulmonary function indices, especially of diffusion capacity, during a follow-up of 24 months. Because pigeon-breeder's lung caused by free-roaming city pigeons has not been previously described, it remains unclear whether this family developed the disease because of high antigen exposure or because of increased susceptibility. None of the supposedly high-risk human leukocyte antigen types were found in the children. Whether human leukocyte antigen B7 in 1 child played a role in the course of the illness remains speculative. It is unknown to what extent pigeon-breeder's lung caused by nondomestic birds remains undetected and misdiagnosed as difficult or steroid-resistant asthma. The question remains whether free-roaming city pigeons are indeed a public health risk. We suggest that atypical outdoor antigens be considered in all patients with nonresolving chest disease or therapy-resistant asthma.

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15/145. Inhaled corticosteroids and churg-strauss syndrome: a report of five cases.

churg-strauss syndrome is an eosinophil-associated, small vessel granulomatous vasculitis, characterized by late onset asthma, upper airways disease, eosinophilia, and clinical manifestations of systemic vasculitis. Several cases of churg-strauss syndrome have been recognized in patients treated with cysteinyl leukotriene-receptor antagonists and weaned off systemic corticosteroids. These cases have led to a general warning on the possible development of Churg-Strauss syndrome after taking cysteinyl leukotriene-receptor antagonists. The authors report five cases of churg-strauss syndrome in severe steroid dependent asthmatics in whom inhaled corticosteroids allowed systemic corticosteroid withdrawal. It is concluded that physicians should monitor patients carefully when severe asthma is controlled with any substance allowing withdrawal from (or even avoidance) of systemic corticosteroids. case-control studies should identify more precisely the risk factors of churg-strauss syndrome.

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16/145. churg-strauss syndrome associated with montelukast therapy.

churg-strauss syndrome is a rare form of eosinophilic vasculitis associated with asthma. There have been several recent case reports of the condition in association with leukotriene antagonists and it has been speculated that the churg-strauss syndrome was unmasked when oral corticosteroids were withdrawn. We report a case of churg-strauss syndrome associated with montelukast therapy in an asthmatic patient in whom there had been no recent oral corticosteroid use. We believe that this is the first such reported case and would suggest that clinicians need to be vigilant in all patients who develop systemic symptoms when starting treatment with leukotriene antagonists.

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17/145. The "Peter Pan" syndrome and allergy practice: facilitating adherence through the use of social support.

The complexity of care of some patients in an allergy-immunology practice may be increased by behavioral abnormalities of the patients. Facilitating adherence through the use of social support may be the most effective treatment strategy for some of the most difficult of these patients. We report three patients whose medical management problems were alleviated largely because of the participation of their support system. All three patients were stabilized because of the acceptance of responsibility and support of the physician by the designated member of the patient's support system. The range of social support used to manage nonadherent patients ranged from directly providing instructions to a family member to the consistent presence of a spouse or companion at multiple clinical visits. In all cases, the success in management was attributed largely to the presence of a support system.

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18/145. pulmonary eosinophilia after substitution of aerosol for oral corticosteroid therapy.

Three patients with chronic asthma developed pulmonary eosinophilia while oral prednisolone was being withdrawn after the introduction of treatment with beclomethasone dipropionate aerosol. These observations suggest that the development of pulmonary eosinophilia in patients with chronic asthma can be prevented by the systemic administration of corticosteroids, but not by a corticosteroid aerosol given by inhalation. It is considered that radiological examination of the chest should be carried out at frequent intervals during and for a few months after the substitution of corticosteroid aerosol therapy for oral corticosteroid therapy in order to ensure that those patients who are liable to develop pulmonary eosinophilia will be identified at an early stage. These precautions are even more essential when there is a previous history of pulmonary eosinophilia.

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19/145. Unilateral fixed dilated pupil in a ventilated child with asthma.

An 11-year-old boy known to have asthma was referred to our intensive care unit (ICU) with progressive respiratory distress. He was sedated, paralysed, and intubated approximately 3 hours after arrival and nebulization with salbutamol and ipratropium was continued on the ventilator. About 16 hours later, he presented with transient unilateral fixed dilated pupils which resolved spontaneously without any neurological deficit. Computerized tomography scan revealed no signs of generalized cerebral oedema. Local contamination with ipratropium was most likely to be the cause of pupil dilatation, which could have occurred during connecting and disconnecting the nebulization system or through contaminated hands.

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20/145. Tension pneumoperitoneum aggravating respiratory failure. A case report.

A case of tension pneumoperitoneum secondary to barotrauma is reported. Any patient needing high pressures for ventilation and oxygenation is prone to this complication. The important respiratory and haemodynamic implications are discussed. It is suggested that drainage of a tension pneumoperitoneum is easy and safe and has major beneficial effects on the respiratory and cardiovascular systems.

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