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• W2895566070 abstract "SESSION TITLE: Obstructive Lung Disease SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/09/2018 07:30 AM - 08:30 AM INTRODUCTION: Asthmatic Granulomatosis (AG) is an asthma variant first described in 2012. It involves refractory asthma with histologic findings of non-caseating granulomas. Most cases of AG improve after starting immunosuppressive therapy [1]. We present a patient who has no recovery on all known therapies. CASE PRESENTATION: A now 40-year-old man presented with a severe asthma exacerbation at age 35. He was previously symptom-free for 27 years. His asthma treatment escalated to include long-acting beta-agonist, long-acting muscarinic-antagonist, leukotriene receptor antagonist, and inhaled corticosteroids. Attempts to wean oral corticosteroids less than 30 mg/day caused relapse. A comprehensive evaluation including multiple bronchoscopies, diagnostic cultures, hypersensitivity pneumonitis panel, connective tissue disorder testing, and gastrointestinal assessment were all negative. Chest imaging showed minimal changes. Eventually, video-assisted thoracoscopic surgery (VATS) was performed and a lung biopsy revealed AG. The patient then unsuccessfully tried multiple therapies including bronchial thermoplasty, mycophenolate, mepolizumab, reslizumab, and omalizumab. Azathioprine induced a severe systemic inflammatory reaction and intravenous immunoglobulin resulted in aseptic meningitis. The patient is currently being evaluated for treatment with a Janus kinase (JAK) inhibitor, tofacitinib, and lung transplant. DISCUSSION: AG is a pathologically distinct entity that mimics severe refractory asthma. Current literature describes AG with asthmatic changes, such as large airway submucosal inflammation and muscular hypertrophy, in addition to small airway interstitial non-caseating granulomas [2]. Prior studies showed improvements in symptoms, lung function, and oral steroid dose while on immunosuppressive agents. Our patient has shown no improvement and severe side effects on these same medications. He is now undergoing therapy with a medication that, to our knowledge, has never been used before pursuing transplantation. CONCLUSIONS: AG should be considered in asthmatic patients unresponsive to standard asthma treatment. This case reinforces the idea of pursuing early lung biopsy in cases of refractory asthma for accurate diagnosis, early targeted intervention, and to highlight a case that is defying all the rules. Reference #1: Wenzel SE, Vitari CA, Shende M, et al. Asthmatic granulomatosis: a novel disease with asthmatic and granulomatous features. Am J Respir Crit Care Med. 2012;186:501–507 Reference #2: Trejo Bittar HE, Doberer D, Mehrad M, et al. Histologic Findings of Severe/Therapy-Resistant Asthma from Video-Assisted Thoracoscopic Surgery Biopsies. The American journal of surgical pathology. 2017;41(2):182-188. DISCLOSURES: No relevant relationships by Rakin Choudhury, source=Web Response No relevant relationships by Helen Hashemi, source=Web Response Speaker/Speaker's Bureau relationship with Astra Zeneca Please note: $5001 - $20000 Added 02/21/2018 by Mark Millard, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Bohringle Ingleheim Please note: $5001 - $20000 Added 02/21/2018 by Mark Millard, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Circassia Please note: $1001 - $5000 Added 02/21/2018 by Mark Millard, source=Web Response, value=Honoraria Advisory Committee Member relationship with Novartis Please note: $1001 - $5000 Added 02/21/2018 by Mark Millard, source=Web Response, value=Honoraria Advisory Committee Member relationship with GSK Please note: $1001 - $5000 Added 02/21/2018 by Mark Millard, source=Web Response, value=Honoraria" @default.
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• W2895566070 date "2018-10-01" @default.
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• W2895566070 title "SEVERE ASTHMA CAUSED BY THERAPY-RESISTANT ASTHMATIC GRANULOMATOSIS" @default.
• W2895566070 doi "https://doi.org/10.1016/j.chest.2018.08.672" @default.
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