A case of cyclical asthma exacerbations and associated left upper lobe collapse

HISTORY OF PRESENT ILLNESS The patient is a severe steroid-dependent asthma sufferer from the age of 5 years, whose symptoms had become more difficult to control over the previous 5 months before this presentation. Throughout her childhood she has had frequent asthma exacerbations with multiple hospitalizations, although she has never required airway intubation. Her asthma triggers include upper respiratory tract infections, exercise, sinusitis, and gastroesophageal reflux. To achieve asthma control as a child, she had near continuous dependence on oral corticosteroids. As a consequence of the chronic steroid use, she had significant delay in growth and onset of puberty, only recently starting her menses at age 15. The patient has a history of mild seasonal allergic rhinitis with positive skin prick tests to grass, weeds, trees, molds, cat, dog, and dust-mite. Trials of aeroallergen immunotherapy were attempted at the ages of 7 and 11 but discontinued because of frequent asthma exacerbations interfering with progression of her immunotherapy schedule as well as a lack of clinical improvement. By approximately age 13 the patient’s asthma had substantially improved and her exacerbations became less frequent. She was successfully tapered off oral corticosteroids for several months at a time. Her rhinitis symptoms had also improved and she no longer required daily medical therapy. Five months ago, however, the patient’s asthma worsened for unclear reasons, developing recurring episodes of wheezing and shortness of breath accompanied by drops in her peak expiratory flow rate (PEFR) from her baseline of 300 to 380 L/minute down to 200 to 250 L/minute. During each exacerbation her symptoms improve with a prolonged course of corticosteroids (prednisolone 16 mg twice a day for 10 days) followed by a slow taper more than 2 to 3 weeks (down to 4 to 8 mg daily). Near the end of the taper, however, she flares up again suddenly. During this period she denies any symptoms suggestive of a recent upper respiratory infection, sinusitis, or rhinitis and also has not had any changes in her environment. Five months earlier she had also complained of heartburn symptoms and a 24-hour pH probe study revealed significant gastroesophageal reflux. She was subsequently treated appropriately and had resolution of her reflux symptoms, but demonstrated no improvement in her asthma. This presentation is the fifth consecutive month of recurring exacerbations and her symptoms are consistent with previous flare-ups except for the presence of pleuritic chest pain. She denies any fevers or upper respiratory tract infection symptoms. Her PEFR has decreased to a plateau of 200 L/minute, without variability over the previous 5 days. The patient’s maintenance medications include fluticasone propionate (Flovent; GlaxoWellcome, Research Triangle Park, NC), 220 g, 4 puffs twice a day; salmeterol xinafoate (Serevent; Glaxo Wellcome), 2 puffs twice a day; omeprazole (Prilosec; Astra Zeneca, Wilmington, DE), 40 mg daily; ranitidine, 150 mg every night; and albuterol sulfate metered-dose inhaler (90 g/dose) as needed. She also started prednisolone, 32 mg twice daily, 3 days before presentation without any improvement in her symptoms.