A 23-year-old man is experiencing a flare of his asthma. He is using his salbutamol inhaler more frequently than usual and despite increasing his inhaled steroids he is still short of breath. Previously, his asthma was considered mild with no severe exacerbations requiring oral steroids or hospitalization. With the current flare, he is experiencing recurrent episodes of bronchial obstruction, fever, malaise, and expectoration of brownish mucous plugs. On examination, there is bilateral wheezing. The heart, abdomen, neurologic, and skin exams are normal. A CXR reveals upper lobe pulmonary infiltrates; the eosinophil count is 3000/mL, and serum precipitating antibodies to Aspergillus are positive. Which of the following is the most likely diagnosis?
ascaris infestation
allergic bronchopulmonary aspergillosis
Churg-Strauss allergic granulomatosis
Loeffler syndrome
Allergic bronchopulmonary aspergillosis (in asthmatics) is the most likely diagnosis in this patient. Other causes of pulmonary infiltrates and eosinophilia include parasitic reactions, drugs, idiopathic causes which includes Loeffler syndrome (benign, acute eosinophilic pneumonia), chronic eosinophilic pneumonia, hyper eosinophilic syndrome, and Churg-Strauss allergic granulomatosis.
Respiratory