Severe ketorolac-induced asthma diagnosed by chest CT

Introduction: Aspirin-exacerbated respiratory disease (AERD) affects 15% of severe asthmatics and drug reactions cause 200.000 annual deaths in Europe. Case report: A 65-year-old lady presented to emergency for progressive abdominal pain. Her medical history included gallstones, asthma, rhinosinusitis, arrhythmia and hypertension. She was medicated with inhaled fluticasone, vilanterol and tiotropium, oral pantoprazole and perindopril, and nasal budesonide. She reported partial asthma control and an exacerbation requiring admission to a Respiratory Medicine ward six weeks before. On examination, there was right upper quadrant tenderness and no other changes. Blood tests were normal, and an ultrasound showed gallbladder stones with normal wall. Intravenous ketorolac led to prompt pain resolution. After 30 minutes she became severely dyspneic, with an O2 saturation of 85% on high flow O2. She had no breath sounds on the left lung, and there was no wheezing or prolonged expiration. A chest X-ray showed no pneumothorax and a CT angiography was performed showing bilateral mucoid impaction and sub-segmental atelectasis (Fig. 1). Conclusion: This report illustrates both an intravenous NSAID causing severe AERD, and how a chest CT may be instrumental for the diagnosis of life-threatening asthma. (Figure 1)