Recurrent Bronchiectasis Exacerbation With Aspergillus Sensitivity in a Patient Common Variable Immunodeficiency and Obstructive Lung Disease - A Delicate Balance Between Anti - Infective and Immunotherapy

Document Type

Conference Proceeding

Publication Date

5-2025

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Introduction Approximately 34% of patients with Common Variable Immunodeficiency (CVID) develop bronchiectasis:15-50%experience obstructive lung disease. Allergic Bronchopulmonary Aspergillosis (ABPA) is seen in 28-34% of asthma patients but is rare in bronchiectasis (3-6%). Aspergillus sensitization without ABPA also occurs in this cohort. Systemic steroids, which are the mainstay for the management of ABPA/COPD exacerbations, are typically avoided during bronchiectasis exacerbations related to active infection. We present a case of bronchiectasis in a CVID patient with concurrent severe asthma-COPD overlap       syndrome (FEV1 25%), Aspergillus sensitivity, and management with both anti-infective and immunotherapy. Case Report An 83-year-old male with CVID, bronchiectasis with recurrent exacerbations, asthma-COPD overlap syndrome, and chronic respiratory failure (requiring 3-4 L oxygen at home) presented with dyspnea and increased sputum production. His home medications included ICS-LABA, monthly IV immunoglobulin (IVIG), benralizumab injections (every 8 weeks), inhaled ceftazidime, and oral doxycycline. His medical history was notable for respiratory colonization with *Pseudomonas aeruginosa*, *Pasteurella*,*Aspergillus*, and ESBL *E. coli* pneumonia. Immunoglobulin subclassification showed decreased IgG1 (290 mg/dL), increased IgE (1908 IU/L), and an eosinophil count of 0.The patient was treated with a 5-day course of IV ceftriaxone and doxycycline. On day 4, he received IVIG; it was noted that he had missed his last three IVIG doses. Respiratory cultures on day 4 grew *Aspergillus fumigatus*. Given prior *Aspergillus*colonization, lack of eosinophilia, and stable imaging, antifungals were not initiated. Despite initial improvement, his dyspnea worsened on day 5, and he was started on prednisone 20mg BID for 5 days for a COPD exacerbation, resulting in improvement and discharge. He was readmitted 3 weeks later with similar symptoms. ABPA testing revealed elevated total IgE (1939 kU/L)and Aspergillus-specific IgE (>100 kU/L), with an eosinophil count of 0.0 billion/L. HRCT showed stable moderate to severe cystic/saccular bronchiectasis in the right lower lobe. He was prescribed a 3-month tapering course of prednisone 20mg daily. Discussion Our patient was treated for bronchiectasis and COPD exacerbation. Although he had Aspergillus sensitization, he did not meet the criteria for ABPA. Since he missed his last two IVIG doses, restarting immunotherapy may have increased his reactivity to existing Aspergillus in the airway. Aspergillus sensitization in patients with obstructive airway disease has been associated with more frequent and severe exacerbations due to an enhanced Th2-mediated response. This highlights the utility of systemic steroids for bronchiectasis exacerbations in this case.

Volume

211

First Page

A4104

Comments

American Thoracic Society (ATS) International Conference, May 16-21, 2025, San Francisco, CA

Last Page

A4104

DOI

10.1164/ajrccm.2025.211.Abstracts.A4104

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