Correct!
5. All of the above
Central bronchiectasis is often seen in ABPA and is believed to be due to the presence of chronic mucoid secretions leading to irreversible airway damage. Mucus plugging can lead to lobar or segmental airway collapse and the “finger in glove” opacity where thick mucoid secretions occlude a bronchiectatic airway leading to the appearance of the “finger-in-glove” on the CT scan. The signet ring shadow is due to dilated bronchi being seen en face and is thought by many to be pathognomonic for Aspergillus related lung disease. Additional radiographic findings include tramline shadows due to bronchial widening, scattered nodular, micro-nodular and tree-in-bud opacities as well as fibrotic scarring with cavitation.
Case Continued:
She was taken to bronchoscopy to evaluate the collapsed left upper lobe. In the bronchoscopy suite, thick white mucus was suctioned out of the right middle and right upper lobe. There were no endobronchial lesions on the right side. On the left side, similar appearing thick white mucus was again encountered and required heavy suctioning. The left upper lobe bronchus was completely filled with thick white to brown appearing mucus. Multiple attempts to suction it clear were unsuccessful. The patient experienced refractory hypoxemia and required endotracheal intubation. She was then taken to the Intensive Care Unit. The following day bronchoscopy was repeated and multiple thick dark appearing mucus plugs were suctioned from the airway. See Figure 2. Following this the left upper lobe bronchus, lingual sub-division, apical-posterior sub-division and anterior sub-division bronchi all appeared open and patent.
Figure 2. Multiple thick, dark mucus plugs removed during bronchoscopy.
Which of the following best describes the treatment of ABPA? (Click on the correct answer to proceed to the fifth of six panels)