A case of chest pain variant asthma]

A 45-year-old woman afflicted with bronchial asthma consulted our hospital because of severe constricting pain at the sternal area. Her chest pain improved with montelukast, and she was diagnosed to have chest pain variant asthma. Chest pain variant asthma is rare.     

Bronchial biopsy and reactivity in patients with chest tightness relieved with bronchodilator

Objective: It has been hypothesized that some patients with chest tightness of unknown origin can be successfully treated with a bronchodilator and that they should be diagnosed with chest pain variant asthma. We conducted a prospective study to characterize newly diagnosed patients with chest tightness relieved with bronchodilator use and without characteristic bronchial asthma attacks. Methods: Eleven patients were registered following recurrent positive responses of chest tightness to inhalation of a ß₂-agonist. These patients underwent assessments of airway responsiveness to methacholine, bronchial biopsy and bronchial lavage under fiber-optic bronchoscopy before receiving treatment. Results: For the patients with chest tightness relieved with bronchodilator use, the bronchial biopsy specimens exhibited significant increases in lymphocyte and macrophage infiltration (p < 0.05) and no significant increase in eosinophils (p = 0.2918) compared with the control subjects. The bronchial responsiveness to methacholine was increased in two of the patients with chest tightness, and it was not increased in seven; in addition, increased percentages of eosinophils were detected in bronchial lavage fluid (5% or more) from two patients, but no increase was detected in eight patients. Conclusions: We suspect that the chest tightness was induced by airway constriction in these patients, but further study is necessary to validate this hypothesis. We propose that the chest tightness relieved with bronchodilator use was attributed to airway constriction resulting from inflammation with lymphocytes and macrophages and/or that the chest tightness was directly attributed to airway inflammation. This clinical trial is registered at www.umin.ac.jp (UMIN13994 and UMIN 16741).     

Chest pain variant asthma

We present the cases of three patients who initially presented with chest pain but were ultimately diagnosed as having asthma. None had audible wheezing. A diagnosis of asthma was entertained and ultimately supported by a clinical response to bronchodilator therapy. Only one patient had significant but intermittent documentable reversible airway obstruction, while another had marked sensitivity to methacholine bronchial challenge. Two patients required short courses of oral corticosteroids before symptom ablation.     

Bronchodilator-resistive cough in atopic patients: bronchial reversibility and hyperresponsiveness.

The number of atopic patients presenting only chronic non-productive cough appears to be increasing. This study was conducted to confirm the existence of non-asthmatic cough associated with atopy. We prospectively examined atopic findings, therapeutic effects of inhaled procaterol, azelastin, and/or glucocorticoids, improvement of FEV1 by bronchodilator therapy and bronchial responsiveness to methacholine in 20 patients. The cough was relieved by inhaled procaterol in 10 patients (Group 2) but not in the other 10 patients (Group 1). The increase in FEV1 by inhaled salbutamol following aminophylline injection was significantly less in Group 1 than in Group 2. Bronchial responsiveness to methacholine was normal in Group 1 while that in Group 2 was hyperreactive. These findings indicate that there is atopic non-asthmatic bronchodilator-resistive cough (Group 1) which is a different entity from bronchodilator-responsive cough (Group 2), or the so-called "cough variant asthma".     

High prevalence of asthma in patients with bronchiectasis in Hong Kong.

Eighty five Chinese patients with diffuse or localized bronchiectasis (non-cystic fibrosis) were studied regarding the prevalence of asthma. Twenty three of the 85 had concomitant asthma, diagnosed by history and reversibility on lung function testing either spontaneously or after bronchodilator. None fulfilled the diagnostic criteria of allergic bronchopulmonary aspergillosis (ABPA). Asthma preceded the onset of bronchiectasis in 13 patients and developed after long duration of bronchiectasis in seven, while the temporal onset could not be differentiated in three patients. Patients with both asthma and bronchiectasis had inferior spirometric values, higher prevalence of bronchial hyperresponsiveness to methacholine, higher prevalence of skin atopy, elevated serum immunoglobulin E (IgE), and more sputum eosinophilia, compared with their non-asthmatic counterparts. Possible mechanisms by which asthma and bronchiectasis predispose to each other include asthmatic obstruction contributing to development of bronchiectasis, and sensitization of airways with increased lability due to microbial colonization of the ectatic bronchial tree.     

Two cases of allergic bronchopulmonary mycosis caused by Schizophyllum commune in young asthmatic patients]

We report on two patients, a 27-year-old and a 33-year-old woman, with allergic bronchopulmonary mycosis (ABPM) caused by the basidiomycetous fungus Schizophyllum commune (S. commune). Each patient had bronchial asthma. Both were admitted to our institution for further examination of cough, sputum, and abnormal chest shadows. ABPM was strongly suspected, because they showed eosinophilia in both peripheral blood and sputum, and increased serum IgE levels. A mold was isolated from their sputum, but identification was not possible. Systemic corticosteroid therapy relieved their symptoms and chest abnormal shadows. Later, S. commune, a basidiomycetous fungus, was detected from further examination of their sputum cultures, and serum anti-S. commune IgG was elevated. Finally, both cases were diagnosed as ABPM caused by S. commune. It is reported that this syndrome typically develops in women in middle age, but our patients were young women. It is important to take into account the possibility of ABPM caused by S. commune even in young patients when Aspergillus species are not isolated.     

Churg Strauss syndrome after introducing oral steroid to inhaler: a report of three cases

The tetrad of bronchial asthma, severe sinusitis, nasal polyp, eosinophilia, and systemic vasculitis is the main feature of allergic granulomatosis and angitis (Churg- Strauss Syndrome). This vasculitis is usually seen idiopathic in patients with a long history of asthma; oral steroids using steroid inhalers, vaccination and desensitization might be triggering factors. Drugs such as leukotriene receptor antagonists (LTRAS), penicillin, sulphonamides, anticonvulsants and thiazides have also been implicated. By presenting the cases in this article, the authors suggest that some cases of CSS may be partially or totally suppressed by corticosteroid therapy of asthma for long periods and replacing oral steroid by inhaler will reveal a pathologic condition of CSS, called frustes CSS forms. We report three subjects with asthma who had been receiving previously multiple corticosteroid courses for control, but when systemic corticosteroids were discontinued or switched over to steroid inhaler, the patients developed a similar syndrome.     

A case of eosinophilic lung disease presenting asthma-like symptoms and centrilobular shadows in both lung fields]

This case, in a 23-year-old man presenting with cough, sputum, dyspnea on effort and wheezing, had been diagnosed as bronchial asthma at another hospital. Because inhaled steroid and theophylline were far from effective, he was admitted to our hospital for further evaluation. A blood test revealed marked eosinophilia. Chest radiography showed diffuse, small nodular shadows in both lung fields, and a chest CT scan demonstrated diffuse centrilobular nodules and thickening of the bronchi and bronchioles. A spirometric test showed obstructive and restrictive ventilatory impairment, but the depressed forced vital capacity failed to show improvement in response to bronchodilator inhalation, discouraging a diagnosis of asthma. Eosinophilic lung disease with prominent eosinophilic bronchiolitis was diagnosed on the basis of BAL eosinophilia and thoracoscopic lung biopsy findings. The symptoms and blood eosinophilia were responsive to administration of oral prednisolone (30 mg daily); radiographic and CT findings also showed improvement. This case showed a marked similarity to the recently reported "eosinophilic bronchiolitis", and was probably not a type of bronchial asthma.     

剂量反应曲线斜率在支气管哮喘中的诊断价值

目的探讨剂量反应曲线斜率(DRS)对支气管哮喘的诊断价值。方法对101例支气管激发试验阳性患者随访2年,4例失访,将患者分为两组,其中56例患者临床确诊为支气管哮喘,为哮喘组;41例未诊断哮喘的患者为非哮喘组。计算DRS,用ROC曲线评价DRS在诊断哮喘中的敏感性和特异性。结果ROC曲线下面积为81.8%,DRS最佳截点为22.28,敏感度为62.5%,特异度为92.7%。结论支气管激发试验阳性联合DRS可提高支气管哮喘诊断的特异度。     

呼出气一氧化氮检测对咳嗽变异性哮喘的诊断价值

目的 探讨呼出气一氧化氮(fractional exhaled nitric oxide,FeNO)检测在咳嗽变异性哮喘(cough variant asthma,CVA)诊断中的应用价值.方法 回顾性研究分析2015年1月至2015年12月我院呼吸科门诊及住院,因慢性咳嗽同时行支气管激发试验(bronchial provocation test,BPT)检查及FeNO检测的患者共989例.以BPT阳性作为诊断CVA的金标准,记录患者病史及FeNO水平;绘制受试者工作特征(ROC)曲线,探讨诊断CVA的FeNO阈值.结果 989例被纳入研究的患者中,120例BPT阳性者诊断为哮喘组,869例BPT阴性者诊断为非哮喘组.哮喘组患者FeNO水平[(61.28±41.24) ppb]明显高于非哮喘组[(25.43±24.87) ppb],差异有统计学意义(P＜0.01).诊断CVA的FeNO阈值为30.00 ppb,ROC曲线下面积为0.804,其约登指数为0.505 2,灵敏度为72.50％,特异度为78.02％,阳性预测值为31.29％,阴性预测值为95.36％,准确度为77.35％.结论 FeNO检测诊断CVA具有较高的特异度和阴性预测值,且安全性好,在临床上有较高的诊断价值.     

A case of smoking-induced chest pain improved with beta2-stimulant

A 24-year-old Japanese man presented with a complaint of chest pressure. He began to have severe chest pressure several times a day. The attack was frequently induced by smoking. During an attack, we gave him an inhalation with procaterol hydrochloride, and his chest tightness disappeared. He was suspected to have chest pain variant asthma. We asked him to stop smoking, and gave him corticosteroid, and his chest pressure did not reappear. This disease is relatively unknown. There is a need for a better dissemination of knowledge about this disease.     

非粒细胞缺乏患者肺曲霉菌病 16 例临床研究简

目的 探讨非粒细胞缺乏肺曲霉菌病患者的临床表现、影像学特点及诊断治疗方法.方法回顾性分析16例确诊的肺曲霉菌病患者的临床资料.结果 曲霉菌球菌病3例,变态反应性支气管肺曲霉菌病1例,侵袭性肺曲霉菌病12例.主要症状为咳嗽、咯痰、发热、咯血、胸闷和气喘,肺部体征不明显.胸部CT表现：双肺多发病灶13例,单病灶3例.所有患者均接受抗真菌药物治疗,死亡6例皆为侵袭性肺曲霉菌病患者.结论 曲霉菌球菌病病情发展缓慢,部分病人需要手术切除病灶;变态反应性支气管肺曲霉菌病情时轻时重,早期常误诊为支气管哮喘;侵袭性肺曲霉菌病情进展迅速,死亡率高,降低病死率有赖于早期诊断及抢先治疗.     

The frequency of self-reported allergic diseases in patients with crimean-congo haemorrhagic fever

BackgroundCrimean-Congo haemorrhagic fever (CCHF) is an acute, tick-borne viral disease. In temperate areas, CCHF cases occur between spring and early autumn when tick activity is high. This period is also the pollen season during which symptoms of allergic diseases are exacerbated. Viruses induce inflammatory and antiviral responses by binding to specific receptors on the surface of airway epithelial cells, resulting in activation of innate immune responses; release of mediators such as cytokines and chemokines; and recruitment of neutrophils and mononuclear cells to the area.AimWe aimed to evaluate the frequency of self-reported allergic diseases and the effect on CCHF severity.MethodBetween June and August 2008, a questionnaire was applied to 114 CCHF (+) patients and 122 healthy control subjects, 16 to 88 years old who attended the Infectious Diseases clinic and were hospitalised with CCHF suspected, by face to face interview including history of allergic rhinitis (AR), asthma symptoms and nonspecific bronchial reactivity, doctor diagnosed AR and/or asthma, and familial allergic diseases history.ResultsAccording to PCR and/or enzyme-linked immunoassay (ELISA) results, 51.7% of patients (n=114) had CCHF. There was no significant relation between CCHF and history of AR, asthma symptoms and nonspecific bronchial reactivity, doctor diagnosed AR and/or asthma, and familial allergic diseases history. The severity of CCHF has not affected these parameters (p>.05). Of patients with positive CCHF test, 2.6% (n=3) and 3.5% (n=4) had doctor diagnosed AR and asthma, respectively.ConclusionSelf-reported allergic diseases and CCHF are not related with each other.     

Management of asthma in children in low-income countries.

Asthma is a common disease in children living in low-income countries. Asthma is diagnosed in children, especially those aged over 2 years, who have wheezing episodes that improve after a bronchodilator is given (bronchodilator response test). Children are classified as having either intermittent or persistent asthma and treated according to the severity of the disease with either an inhaled bronchodilator (reliever) or a combination of an inhaled bronchodilator and inhaled corticosteroid (controller). Treatment is best given by inhalation, and as children under 5 years cannot coordinate their breathing with the multidose inhaler, spacers are required. These can be made locally from plastic bottles. Care givers need to be educated about how to manage asthma and should receive a written management plan on the management of the child's asthma. Children should be examined to see if they are allergic to especially airborne allergens, and if these are present they should be removed from the environment. Adult smoking worsens childhood asthma, and care givers need to be given support with smoking cessation. Regular planned follow-up is needed to ensure that the asthma is well controlled and the lowest dose of inhaled corticosteroid is used. Inhaled bronchodilators and corticosteroids must become freely available and should be inexpensive in low-income countries in order to treat childhood asthma correctly.     

Acute myocardial injury and repeated angina pectoris-like attacks in a young patient with Churg-Strauss syndrome]

A 23-year-old male with bronchial asthma developed eosinophilia (eosinophils greater than 2,000/mm3) and was observed at our hospital. After using a prescribed indomethacin suppository for fever at home, he experienced an attack of acute chest pain and severe dyspnea. He suffered cardiac arrest while being transferred to the ward. After resuscitation, he was diagnosed as having acute myocardial infarction on the basis of electrocardiographic and ultrasonic cardiographic findings, and marked elevation of serum concentrations of myocardial enzymes. Thereafter, he often complained of precordial pain and abdominal pain. When he was administered an analgesic in another hospital, he developed severe precordial pain, and marked ST elevation was recorded on the electrocardiogram. Coronary angiography revealed no stenosis nor atherosclerotic changes, suggesting that severe spasm of the coronary arteries and direct myocardial injury by eosinophils were the causes of the myocardial infarction-like symptoms and angina pectoris-like attacks. He was diagnosed as having Churg-Strauss syndrome (allergic granulomatous angiitis) on the basis of the clinical findings; skin biopsy and transbronchial lung biopsy findings were consistent with the diagnosis. Following steroid administration, his angina-like attacks and abdominal pain ceased. This patient developed two episodes of acute cardiovascular symptoms upon administration of antipyretic analgesics. This suggests that in cases of Churg-Strauss syndrome with aspirin-induced asthma, physicians must be aware of the cardiovascular complications, and such drugs should be administered with caution.     

Nickel Sensitivity in Asthma Patients

Nickel sulphate frequently causes allergic contact dermatitis; less known effects are nasal inflammation (rhinitis) and bronchial asthma. In this study, we aimed to find if there is a relationship between asthma and nickel sensitivity. Asthmatic patient, non-asthmatic atopic, and healthy control groups were patch tested with nickel sulphate. Nickel sensitivity was more prevalent in the asthmatic patient group compared to the non-asthmatic atopic and healthy control groups.     

Nickel Sensitivity in Asthma Patients

Nickel sulphate frequently causes allergic contact dermatitis; less known effects are nasal inflammation (rhinitis) and bronchial asthma. In this study, we aimed to find if there is a relationship between asthma and nickel sensitivity. Asthmatic patient, non-asthmatic atopic, and healthy control groups were patch tested with nickel sulphate. Nickel sensitivity was more prevalent in the asthmatic patient group compared to the non-asthmatic atopic and healthy control groups.     

Case of allergic bronchopulmonary aspergillosis triggered by relocation of residence]

A 22-year-old woman has been treated with inhaled corticosteroid for bronchial asthma. Her family moved house to Toyama prefecture in March 2003, and she was enrolled in our hospital. Her chest radiograph on first medical examination showed the right upper lobe infiltration. Bronchoscopy revealed a mucoid impaction at right B2, and Aspergillus fumigatus was cultured from suctioning of pulmonary secretions. Histopathologic findings from transbronchial biopsy revealed eosinophilic pneumonitis but not Aspergillus fumigatus. She was diagnosed allergic bronchopulmonary aspergillosis, and she was started on prednisolone 40 mg/day. The finding of her chest radiograph improved in two weeks. This case suggested that allergic bronchopulmonary aspergillosis was triggered by moving house with exposure of Aspergillus fumigatus. We should give guidance to asthmatics to wear a dust respirator at work in dust-laden environment.     

Eosinophilic airway disorders associated with chronic cough

Chronic cough is a major clinical problem. The causes of chronic cough can be categorized into eosinophilic and noneosinophilic disorders, the former being comprised of asthma, cough variant asthma (CVA), atopic cough (AC) and non-asthmatic eosinophilic bronchitis (NAEB).Cough is one of the major symptoms of asthma. Cough in asthma can be classified into three categories; 1) CVA: asthma presenting solely with coughing, 2) cough-predominant asthma: asthma predominantly presenting with coughing but also with dyspnea and/or wheezing, and 3) cough remaining after treatment with inhaled corticosteroid (ICS) and β2-agonists in patients with classical asthma, despite control of other symptoms. There may be two subtypes in the last category; one is cough responsive to anti-mediator drugs such as leukotriene receptor antagonists and histamine H1 receptor antagonists, and the other is cough due to co-morbid conditions such as gastroesophageal reflux.CVA is one of the commonest causes of chronic isolated cough. It shares a number of pathophysiological features with classical asthma with wheezing such as atopy, airway hyperresponsiveness (AHR), eosinophilic airway inflammation and various features of airway remodeling. One third of adult patients may develop wheezing and progress to classical asthma. As established in classical asthma, ICS is considered the first-line treatment, which improves cough and may also reduce the risk of progression to classical asthma.AC proposed by Fujimura et al. presents with bronchodilator-resistant dry cough associated with an atopic constitution. It involves eosinophilic tracheobronchitis and cough hypersensitivity and responds to ICS treatment, while lacking in AHR and variable airflow obstruction. These features are shared by non-asthmatic eosinophilic bronchitis (NAEB). However, atopic cough does not involve bronchoalveolar eosinophilia, has no evidence of airway remodeling, and rarely progresses to classical asthma, unlike CVA and NAEB. Histamine H1 antagonists are effective in atopic cough, but their efficacy in NAEB is unknown. AHR of NAEB may improve with ICS within the normal range. Taken together, NAEB significantly overlaps with atopic cough, but might also include milder cases of CVA with very modest AHR. The similarity and difference of these related entities presenting with chronic cough and characterized by airway eosinophilia will be discussed.