Mr. P.L. was a 43-year-old gentleman with a history of asthma since childhood who’d been reasonably stable over the years, save for occasional short-term exacerbations that responded fairly well to a short course of steroids. In February 2008, he presented with increasing shortness of breath and a month-old cough, and was admitted for acute exacerbation of asthma.

A chest x-ray revealed faint left basal infiltrate and it was felt that this episode of “pneumonitis” worsened his underlying asthma and should be treated. His chest x-ray improved with antibiotics, but he continued to have ongoing wheezing and shortness of breath. He was discharged home on a course of oral azithromycin and prednisone 50 mg/day for a week.

He’d been on theophylline 600 mg bid, salbutamol sulfate 2 puffs qid as required, fluticasone/salmeterol 500 μg bid, montelukast sodium 10 mg/day, ketotifen 20 mg/day, and fluticasone propionate nasal spray.

His past medical history was remarkable for mechanical low back pain. For this he’d been on cyclobenzaprine 10 mg tid, acetaminophen 1 gm tid as required, diclofenac/cytotec 75 mg as required, oxycodone/acetaminophen one tablet tid, as required. Because of his ongoing lower back symptoms, transdermal fentanyl 75 μg every 72 hours was added to therapy in January 2008.

He continued to have difficulty with breathing and audible wheeze, especially in the upper airways. Further chest
x-rays remained normal, including a CT chest scan that failed to show any endobronchial or obstructive process. Pulmonary function test showed airway obstruction. Sputum cultures remained negative. He had no known allergies and denied any skin rashes or symptoms of joint pains, fever or chills. He denied symptoms of post-nasal drip, heartburn or reflux. But in view of persistent and ongoing symptoms of “asthma exacerbation,” the possibility of reflux contributing to symptoms was entertained and he underwent gastroscopy. That too was unremarkable, except for mild gastritis, for which esomeprazole 40 mg/day was added to therapy.

Four months later

Despite optimal bronchodilator therapy, antibiotics, 3 courses of oral prednisone, anti-reflux therapy, negative bronchoscopy and CT scan of chest, his symptoms continued for over 4 months. Lab investigations were remarkable for slightly elevated serum IgE levels and progressively increasing eosinophils. Serum α₁-anti-trypsin was normal and aspergillus antibodies were non-reactive. The possibility of carcinoid syndrome was also considered and ruled out with normal urinary 5-HIAA level.

What’s causing this persistent episode of exacerbation of asthma?